Report received.
	Clause 1 [General duties of local authority in relation to well-being of young children]:

Baroness Morris of Bolton: My Lords, in Grand Committee, I explained that Amendments Nos. 1 and 3 remove the words "reduce inequalities" in subsection (1)(b) and "reduction of inequalities" in subsection (3)(b) of Clause 1, which outlines the duty placed on local authorities. The amendments provide substitute wording with emphasis on raising the quality of outcomes for the most disadvantage of our young children.
	The issue of reducing inequalities between children lies at the heart of the Bill, and yet it raises fundamental questions about what exactly this phrase means, how it will be measured, and how it will be delivered. It goes without question that we would all wish to give every child the very best start in life. That is an aim that I wholeheartedly endorse, particularly in the wake of the Government's failure to meet their target for reducing child poverty. A good start in life not only produces a better result for each child, but is good for their family and society as a whole and, as the Government rightly point out, will, it is hoped, lessen the chances of needing later intervention.
	We must support and improve the well-being of children in the broadest sense, but it is vital to place the most vulnerable and disadvantaged at the heart of our deliberations, and to focus resources to meet their needs. We had an interesting debate in Committee in which I highlighted our concern that the terminology in the Bill—to "reduce inequalities"—not only lacks clarity but could lead to levelling down rather than the much needed hand up that these children require. The wording that we propose not only focuses on,
	"the quality of outcomes of the most disadvantaged",
	but requires improvement in those outcomes.
	In his response in Grand Committee, the Minister had two main rebuttals. The first was that the amendments could result in a straightforward watering-down of the Bill, arguing that the idea of levelling down would be contrary to the duty to improve the well-being of children in Clause 1. He suggested that it was mind-boggling to try to understand how a local authority could go about reducing the advantages and performance of some compared to others or, as he put it, the more advantaged. The second argument was that we only need look at the abundant evidence of what the Government have done in early years provision since 1997. While I have no desire to cast a shadow over some of the significant achievements of this Government, I respectfully disagree. We need to look only at Sure Start to see that it has not been working as it should have been and still leaves out the neediest, whom the Minister suggests that the Government's systems have included, a subject to which I shall return in a minute.
	I would also like to add a word on resources here, in advance of the debate that we will have on Clause 6. We live in a world of limited resources and, in this case, one where the LGA has grave concerns about its ability to deliver such an ambitious project. Surely in such circumstances it is better to focus what there is on the most vulnerable. The issue must now be viewed in the light of the recent admission by the Prime Minister in his Let's Talk initiative that Sure Start for under-fives and policies for children in care have failed the socially excluded. I am sure that the Minister will be pleased to know that that serves only to strengthen my resolve on the issue. The Prime Minister is reported in the Guardian as saying, of the multi-billion pound Sure Start scheme:
	"If we are frank about it, there is a group of people who have been shut out against society's mainstream and we have not yet found a way of bringing them properly in. When we started Sure Start—I was always a bit sceptical that in the end that we could do this—there was an idea it would lift all the boats on a rising tide. It has not worked like that".
	That is why we believe that the focus should be on those most disadvantaged. The Prime Minister stated that Sure Start has not worked, and admitted that there need to be "different systems of delivery" and that,
	"the hard to reach families, the ones who are shut out of the system . . . are not going to come to places like Sure Start".
	His comments not only go against those made in objection to the amendments in Committee, but support our amendments. We really should put the emphasis on the quality of outcomes for the most disadvantaged into the Bill.
	I turn to Amendments Nos. 2, 4 and 5. Clause 1 gives the Secretary of State the power to set statutory targets for local authorities relating to,
	"the improvement of the well-being of young children".
	That links into the questions that I have just raised on how inequalities are to be measured. Amendments Nos. 2 and 4 remove the words regarding targets from Clause 1(3) and (4) and replace them with "establish procedures for assessing". Amendment No. 5 aims to ensure that, in exercising their functions, local authorities do not concentrate on meeting one duty to the detriment of another.
	As your Lordships know, this Government are particularly fond of targets, but a wealth of targets can often move the focus away from the root of the problem and make it simply an exercise in numbers. The discussions that we had in Committee highlighted the concern that targets had the potential to have unforeseen consequences. Briefing that we received from the National Children's Bureau summed up fears that,
	"targets will distort priorities, create unintended consequences and distract professionals from the real task of meeting children's needs, as they exist, in the round".
	The aim of our wording is to replace the idea of central targets with provisions to monitor the performance of local authorities in improving outcomes.
	The Government's document, Childcare Bill: Duty to improve well-being and reduce inequalities in outcomes for children up to 5, provides helpful detail as to how they envisage the proposed targets to work. It also tells us that local authorities' performance in childcare is already subject to inspection and monitoring via Ofsted, the Commission for Social Care Inspection and, most recently, the joint area reviews. All of that is additional to the local authorities' own performance data. In Grand Committee, the Minister did not update the House on the results of the joint area reviews that have taken place since last year. I hope that he will do so in his response today.
	The LGA argues that progress on improving outcomes according to the five Every Child Matters outcome measures is exactly what the joint area reviews were established to assess—not based on targets, but a holistic assessment of performance, including self-evaluation and input from children themselves. The duty to improve outcomes in Clause 1 echoes existing duties under Sections 10 and 11 of the Children Act 2004. Assessment and monitoring procedures are already provided for in that Act; thus, the imposition of additional targets seems repetitive and unnecessary.
	The Minister argued in Grand Committee that targets were to complement and reinforce the Government's desire for a robust improvement of strategies. Indeed, he said that they were to help early childhood services establish equivalent status within more established local authority services. Whatever the desire, we feel that this is one set of targets too many. After all, as the Minister stated, with the exception of local authorities that are deemed to be excellent, all local authorities are required to prepare and publish their plans for children and young people, setting out their strategies to improve the well-being of children. Does the Minister not agree that that requirement already ensures that these issues have an equivalent status to other duties?
	The National Children's Bureau believes that the new targets outlined by the draft statutory guidance regarding the outcomes for children and narrowing the gap between children with the poorest outcomes in the rest of England already exist in another form. Interestingly, it was a matter that we did not discuss in Grand Committee: the Sure Start unit's public service agreement target from the 2004 spending review, which aims to
	"improve children's communication, social and emotional development so that by 2008 50% of children reach a good level of development at the end of the Foundation Stage and reduce inequalities between the level of development achieved by children in the 20% most disadvantaged areas and the rest of England".
	I have been led to understand that the base-line sample for the Sure Start PSA is the July 2005 results of the foundation stage profile. This means that there has been no analysis of how that PSA is working as data from July 2006 have, of course, not yet been produced and will not be published until December this year. Why do the Government want to enshrine in law the current PSA and introduce a new PSA target before performance against the existing target has been analysed—particularly in light of the recent admission by the Prime Minister regarding the failures of Sure Start? Can the Minister explain how the old and new PSA targets will differ?
	I apologise for taking so long on this matter, but can the Minister say why the draft guidance refers to the "poorest performing young children" while the current PSA refers to "disadvantaged areas"? Can he explain that shift in rhetoric? The noble Baroness, Lady Walmsley, raised questions that merit further answers on how children are to be identified as poorly performing and why that language is used in relation to such young children.
	Our third amendment emphasises that one duty should not be achieved at the expense of another. That ties in with the need for an holistic approach to improving outcomes for our youngest children. I thank the Minister for his response on what happens if an authority excels in one area but not in another and on the potential impact of the Secretary of State. He explained that the Secretary of State could intervene in a proportionate manner. Can he confirm that that will be used only as a last resort when all other routes have been tried?
	I restate what I said in Committee: by setting targets I believe that the Government are undermining the flexibility of local authorities to determine how to meet the needs of young children and parents in their area. That is especially important if they are keen to avoid duplicating the existing provision of the private, voluntary and independent sectors. This is not a numbers game and it most certainly should not be about ticking boxes. I beg to move.

Lord Adonis: My Lords, perhaps the best way of beginning one's remarks in your Lordships' House is to eat humble pie when the Government are at fault, to recognise errors and to seek to correct them immediately. I immediately state that we do not stand by the phrase "poorly performing children". We believe that that is infelicitous wording and will look to change it to see that phraseology that we regard as straightforwardly pejorative is not used.
	I shall deal with two other specifically factual queries for which I have answers. The noble Baroness, Lady Morris, asked whether the current PSA targets will be put into law. We do not intend that to happen. We are reviewing how statutory targets should be set, and we do not intend to use the same form for those targets as is used for the current PSA.
	The noble Baroness also asked what progress is being made with the joint area reviews. I am very sorry that I did not have the information to hand to be able to reply in Grand Committee. Fifteen joint area reviews have been completed so far. These have shown a mix of grades from grade 3, good, to grade 2, adequate, down to grade 1, which is inadequate. Four of the 15 authorities—Herefordshire, Staffordshire, Stoke-on-Trent and Bristol—have had services rated at grade 1, inadequate. Each joint area review includes recommendations to improve services to which authorities must publish an action plan in response. Of course, we will be particularly anxious to pursue those recommendations in the case of authorities whose services have been ranked as unsatisfactory—that is, at grade 1. I think that that reinforces the point that I made in Grand Committee. It is essential that the Government have the capacity to act in seeing that local authorities take their responsibilities seriously when independent inspectors rate their services as inadequate.
	Amendment No. 1 concerns narrowing inequalities. The noble Baroness said in Grand Committee, and repeated again this afternoon, that the test required by the words "reduce inequalities" could be met "grotesquely"—that was the word that she used in Grand Committee—with no improvement at all in the opportunities for the least advantaged if the opportunities for the more fortunate were reduced. The noble Baroness immediately swept aside the fact that I made a full response to that by setting out the importance that the Government attach to raising standards and the level of provision for all children. I will repeat it now, because what we are saying in the Bill in this context is important. There is no point in creating a kind of scare that we could engage in grotesque means of achieving an objective if there is no evidence whatever that that particularly grotesque fear has any chance of being realised. The Government's record since 1997 is one of substantial investment in universal provision for all families with children under the age of five, and I shall go through what we have done to reinforce my point.
	First, the value of child benefit—the main benefit that all parents receive for their children—has gone up by 26 per cent in real terms since 1997, and total government expenditure on child benefit is now approaching £10 billion a year. In 1997, most women were entitled to just 14 weeks' maternity leave. That has now more than tripled to 52 weeks' leave for most and, from April 2007, all employed mothers will be entitled to 52 weeks' leave. In 1997, women who qualified received just 18 weeks' statutory maternity pay. We have since upped that to 26 weeks' pay for all employed women and, from next April, it will be 39 weeks' pay. That increase alone is worth around £1,400 to each working mother. As the House knows, our ambition is to raise the level still further to a full year's pay by the end of this Parliament.
	We have also significantly raised the level of payment. In 1997, the flat rate for statutory maternity pay was £55.60. We have now nearly doubled that to £106, and it is shortly to rise again to £108.85. In this financial year, the Government will be spending £1.4 billion on statutory maternity pay and maternity allowance, which goes to all mothers, irrespective of their income and family circumstances.
	In 2003, we also introduced a brand new entitlement for employed fathers to take two weeks' leave with statutory paternity pay. Again, that had not been available previously; we introduced it as a completely new and universal entitlement. We have done the same in respect of adoption leave and pay. There has also been a huge increase in support for families, up to a considerable level of the income scale, through the introduction of the new tax credit regime. Again, although that is not completely universal, it has covered a very large proportion of the population.
	Specifically in respect of nursery provision for three and four year-olds, in 1997 there was no national scheme of provision for three year-olds and only a patchy scheme of provision for four year-olds. There is now universal entitlement to nursery or equivalent provision for all parents of three and four year-olds, which is very largely taken up, and we have extended the number of hours for which that is available. Perhaps I may give an indication of the scale of commitment that the state has been making to all families in this respect. In 1997, state funding for nursery provision was £600 million a year in respect of free entitlement. That has now risen to £2.9 billion, nearly a 500 per cent increase. I therefore do not believe that we can be accused in any way of neglecting the generality of parents and their needs in framing the new duties under the Bill.
	If there is not an issue about the Government seeking to level down, which emphatically there is not—we are emphatically seeking to level up—we then move on to the issue of how we close the gap between the least fortunate and the more fortunate. We regard that as a very important priority. When speaking in Grand Committee on 19 April 2006, the noble Baroness said:
	"We are about raising standards for all and, if we can, closing the gap between the least fortunate in their accidents of birth, culture and family prosperity".—[Official Report, 19/4/06; col. GC 477.]
	That may underpin the difference between us on the amendments. I was very glad to have the support of the noble Baroness, Lady Walmsley, in this respect. Not only do we want to set this as an attainable objective; we want to provide a very strong imperative for local authorities in how they act in this area by having on the face of the Bill the requirement to narrow gaps in attainment, which will have that effect.
	The research is very clear. The research by Leon Feinstein shows that there is a very close correlation between outcomes at an early age and later in life. Of the cases that he studied, there was a striking relationship between early test scores at 22 months, 42 months and five years and later achievement at A-level or better. Importantly, analysis of the highest and lowest achieving groups showed that the gap evident at age 22 months became ever wider as the months and the years went by. The noble Baroness will be familiar with the Effective Provision of Pre-School Education project which concluded:
	"Disadvantaged children . . . benefit significantly from good quality pre-school experiences",
	especially where they are with,
	"a mixture of children from different social backgrounds",
	which is precisely what we are seeking to achieve in the extension of comprehensive provision for children under five. The EPPE study also concluded that early education,
	"experience, compared to none, enhances children's development".
	On entry to a reception class, the difference in those having attended two years of quality early education and those not is between four and six months' development. That powerfully reinforces the case for a concentration of effort on families who are least advantaged.
	At present, we set out our approach to reducing inequality by concentrating attention in the Sure Start programme on the 30 per cent most deprived Super Output Areas—that is, areas identified through the index of multiple deprivation, a sophisticated tool which measures a wide range of factors including income, employment, health, education and skills, housing and services, crime and the living environment. We chose these precisely defined areas of particular deprivation as an important starting point—I stress "starting point"—in our drive to reduce inequalities, targeting the integrated services of Sure Start children's centres in these areas. This is, however, only a starting point, which is precisely what the Prime Minister meant in his remarks last month—that we have a good deal more to do because we are still in the very early stages of developing under-fives provision. We certainly do not regard ourselves as having yet achieved our objective of eradicating the circumstances of disadvantage that afflict too many families, particularly those at the bottom of the income scale.
	At present, for example, some 25 per cent of young children from deprived backgrounds do not live in the 30 per cent most deprived Super Output Areas. More importantly, barriers to achievement are not limited to social and economic causes. Special educational needs, health, English as a foreign language and other issues of that kind all have a role to play. Under the Bill we wish to develop a new framework, so that instead of authorities having to concentrate exclusively on children from the most disadvantaged areas, they must reduce inequalities by improving outcomes for the young children most at risk of achieving poor outcomes at large.
	Our intention was set out in the outline statutory guidance placed before the House before the Easter Recess. In fulfilling their statutory duty to reduce inequalities, we expect local authorities to identify the characteristics of young children who have the poorest outcomes in the foundation stage profile, and to identify the factors preventing them achieving their full potential. We have no intention of labelling or stigmatising particular groups of young children; rather, we intend to recognise and address the issues hindering them and children in similar circumstances. With this information about the barriers to achievement in their area, local authorities can decide how best to target their resources at the groups most at risk of low achievement.
	The causes of multiple deprivation in the most disadvantaged areas will, I am sure, remain important, but we want authorities to tackle the barriers to achievement which are most appropriate to their area and its particular circumstances. The outline guidance that I made available to the House suggested what some of these might be, and it will be for local authorities to determine the factors most relevant to them.
	I turn now to Amendments Nos. 2 and 4, on statutory targets, and the noble Baroness's concerns about those targets. As I explained in Grand Committee, targets would be based on the foundation stage profile and its successor under the Bill, the early years foundation stage profile. This is a wide-ranging assessment of young children's achievements that has been developed in conjunction with many early-years practitioners and is very widely respected. I also made that available to noble Lords in Grand Committee.
	Since 2003, the foundation stage profile has been recorded for every child at the end of the summer term in their "reception year", the year in which they have their fifth birthday. This information is passed to local authorities, who use it to assess the impact of their work with settings and identify aspects of provision that need further improvement. It is certainly not a large step to suggest that targets at local authority level for improvements in foundation stage outcomes should be the next stage. Authorities are already challenged by strategic advisers over their performance in the foundation stage, and are asked to consider how they can contribute to the Government's PSA target on improving foundation stage outcomes and narrowing gaps. Setting statutory targets for foundation stage performance is the next step in challenging authorities to secure good outcomes for the children in their area.
	As I stressed in Grand Committee, we will seek to agree these targets with local authorities. In Grand Committee, I made available a draft outline of the statutory guidance on the duty to improve well-being and to reduce inequalities in outcome for children up to the age of five. Paragraph 20 of that guidance is explicit that there should be a proper process of consultation with local authorities. It states that,
	"if the Secretary of State proposes to set targets which differ from any proposed by the local authority, she must give an account of her reasons and allow at least one month for the authority to make further representations".
	There is a proper process in train to ensure that we proceed, so far as possible, by agreement.
	The Local Government Association—which I know has been making representations to both noble Baronesses—made clear its concern over statutory targets at an early stage. However, its fears are not shared in the feedback we have received from local authority early years specialists themselves, those who are most closely engaged. As the House may know, we have established a group—the Childcare Implementation Project—which specifically consults early years practitioners in 12 local authorities. It has supported our suggestion of statutory targets for the foundation stage, believing that this will raise the status of early childhood services within their authorities. That is precisely the point I made in Grand Committee. Early years practitioners themselves do not wish to see the attainment of improved outcomes for under-fives as a lesser priority for authorities than is the case, for example, for attainment in schools.
	As I said, the foundation stage develops essential skills in young children, particularly social interaction, communication and such prerequisites of literacy and numeracy as counting and phonics, as well as physical development, creativity and exploration of the world. The foundation stage has the potential to open up a huge world of opportunities for young children regardless of their background. Conversely, failure to develop these key skills in the early years will make subsequent education much harder to access, increasing the likelihood of poor achievement. Without a good start, children are all too likely to fall behind their peers and face an ongoing battle to achieve the same outcomes as their contemporaries. It is precisely because we want to give such priority to achieving improvements in this area—an objective shared on all sides of the House—that it is appropriate for local authorities to set targets in this area.
	Amendment No. 5 seeks to ensure that the two duties in Clause 1—the duty to improve the well-being of young children in their area and the duty to reduce inequalities between young children in their area in the matters set out in the following subsection—could not be met at the expense of each other, which I know has been a concern of the noble Baronesses. We believe that the objective which the noble Baroness has set out is fully met by the wording of the Bill and the ingenious use of the word "and". If the noble Baroness looks at Clause 1, she will see that it sets out the two duties and links them with the word "and". It states that an English local authority must,
	"improve the well-being of young children in their area, and . . . reduce inequalities between young children in their area".
	There is no "or" there. There is no way that a local authority could legitimately interpret its general duties under Clause 1 to give it an opportunity to meet one at the expense of the other. The legal requirements set out in that clause is explicit.
	I am delighted to be able to end by giving such complete satisfaction—I hope—to the noble Baroness. I hope, on that basis, that she might feel able to withdraw her other amendments as well.

Baroness Morris of Bolton: My Lords, I thank the Minister for his full reply and for eating humble pie; I hope it did not taste too horrible. I am pleased to know that the rhetoric will change. I was also pleased to hear what he said about the PSA targets and for his explanation of the joint area reviews. I would like to thank the noble Baroness, Lady Walmsley, for supporting us on the target side. We are very concerned that practitioners are not so busy ticking boxes that it detracts from their vocational work and that we do not place too large a burden on local authorities. It would be awfully nice if we had a target to ditch some of the targets.
	I also thank the noble Lord, Lord Northbourne, for his support on the first group of amendments. I thought long and hard about separating out those two groups of amendments but felt that there were certain themes which made it easier for the Minister to reply to both at the same time rather than having to be repetitive when replying on targets.
	I am very pleased about the word "and", but I do not think that that in anyway detracts from what the noble Lord, Lord Northbourne, was saying—that there really is uncertainly about what "reduce inequalities" means. Recently, I spoke to a group of counsellors and they were not at all sure what it was that they had to do and how it would be measured. Reducing inequalities must take into account a whole host of things outside their duty for childcare: housing, parental involvement, work and the economy. It is open to interpretation and may not be easy to interpret in future. We should concentrate resources on those most in need. It is vital that support for our most disadvantaged is at the heart of our endeavours. However, I beg leave to withdraw the amendment.

Baroness Walmsley: My Lords, I shall speak also to Amendment No. 14, which is grouped.
	The Government have been supportive of listening to young children, as they have demonstrated by funding organisations to conduct research and development projects. They should now cement that commitment into law. A commitment to listening to the views of young children is yet to be enshrined in law, and the Bill gives us an excellent opportunity to do that for the first time.
	The Minister expressed great sympathy with the view that the voice of the child is extremely important from top to bottom of the childcare system, which is why I have brought the amendments back today. I want to give him the opportunity to give us any further reassurances that he is able about the Government's intentions beyond Report.
	The amendments would place a duty on local authorities to take reasonable steps to ensure that the views of young children are incorporated into the design, delivery and evaluation of services. If the Government have been able strategically to use the voices of young children to influence the development of national policy in the form of the early years foundation stage, there is no reason why local authorities should not also be encouraged by legislation to demonstrate that same commitment to involving children from birth in how the authorities undertake their responsibilities.
	The early years foundation stage document states:
	"EYFS requires those who plan and deliver early years provision to put children first; to listen to them and their parents; to observe what they can do; and to make them the most important influence on planning, observational assessment, routine and staffing".
	That should be echoed for local authorities, so that the Bill, when eventually enacted, requires children to be listened to from the beginning to the end of the system and requires those who plan and deliver provision to put them first and to listen to them and their parents.
	Children Now has published its participation charter, which states:
	"Children who are very young, disabled or who have special educational needs have the same right to participate as other children. Services and organisations should be proactive in engaging them, as well as those who are socially or economically disadvantaged, excluded or discriminated against on any basis".
	When we discussed that in Grand Committee, the noble Baroness, Lady Howarth of Breckland, pointed out to us that that is not easy. Listening to young children must be done with great care and expertise. Interpreting and feeding back what they say to the authorities requires a very high level of professionalism. That is not a bad thing.
	The current wording of the Bill ensures that local authorities are limited to taking all reasonable steps to consult the list of groups, to which I want to add young children. That could be reinforced in guidance along with examples of good practice. In Grand Committee, we heard a number of examples where young children had been listened to and great light had been shed on things that were going on in the nursery through the eyes of the children which the practitioners, expert though they were, had not noticed.
	The additional duty of listening to young children is unlikely to be at any significant added cost, because it is fundamental best practice for early years practitioners, which is what the Bill is trying to achieve anyway. Anecdotal evidence from the workforce has also shown us that implementing a listening culture has made workers in the early childhood field more motivated and therefore more likely to stay in their jobs. That, of course, is what we want—a more sustainable workforce that is likely to be of a higher quality for young children and their families because the workers stay in their jobs long enough to really get to know the children and the families and to deliver a good service to them.
	Finally, the omission of young children does not sit well with the UK's obligations under Article 12 of the UN Convention on the Rights of the Child or with the outcome of the contribution made by children to society under the Children Act 2004—the Government's own landmark legislation on children. Given that the Government must report next year on how they are adhering to the UN Convention on the Rights of the Child, placing the voice of the child in the Bill would be a very good way of demonstrating this Government's commitment to children's rights.
	In our previous debate, the Minister was at pains to talk about the importance of putting the principle of reducing inequalities into the Bill. I think he is quite right. Involving the voice of the child at every stage of planning services for their care and early education is another principle that should be enshrined in this legislation, and I hope that the Minister will either accept the amendments or assure the House, which I know feels very strongly about it, that he intends to table his own amendment either at Third Reading or in another place. I beg to move.

Baroness Howarth of Breckland: My Lords, I hope the noble Baroness, Lady Walmsley, when she quoted me was not suggesting that I do not think young children should be in the Bill, because I was the person who produced examples of very young children who were consulted quite successfully. I think they were good examples.
	I do think that there are real advantages to including young children, whether in the Bill—there may be reasons why the Government do not wish to do that—or certainly in guidance, where authorities can develop their programmes of involving young children. That has a real spin-off in a wider sense in that it is of benefit for our democracy. As soon as you start encouraging young children and young people to engage in decisions about their world and themselves, they learn two things: the first is that they might be successful in changing things; the second is that you cannot change everything, and that sometimes you are disappointed. The sooner you learn that, the more likely you are to engage in democracy at a later stage. Therefore, I would be delighted if this was in the Bill, but I would be even more encouraged if it were in guidance.

Lord Adonis: My Lords, we had an excellent debate on this issue in Grand Committee when I said that we were extremely sympathetic to the objective that the noble Baroness seeks to achieve. I pointed out that from the beginning a key feature of the Every Child Matters agenda has been consultation with children who are affected. The original Green Paper in 2003 said:
	"Real service improvement is only attainable through involving children and young people and listening to their views".
	That has also been demonstrated in the creation of the Children's Commissioner whose role is to give a national voice to all children and young people, especially the disadvantaged and the vulnerable.
	The noble Baroness, Lady Howarth, mentioned guidance, which has an important part to play. The current Sure Start children's centre practice guidance published in November 2005 emphasises the importance of involving and consulting everyone who is benefiting, or could benefit, from a children's centre, in particular parents and children themselves as well as those delivering services to families. The guidance goes on to explain how recent projects have shown how children under the age of five can be consulted effectively about the provision of services that they receive through, for example, the use of painting, music, cameras and story telling. It then gives a case study from the Coram family children's centre, with the address of the website where further specialist guidance is available.
	As the noble Baroness, Lady Howarth, said in Grand Committee and repeated today, valuable work is being undertaken in the voluntary sector to produce good practice guidance on consulting with children from organisations which have extensive experience in that area, particularly The Children's Society, Mencap, the Thomas Coram Foundation and the National Children's Bureau. However, this is mainly based on consulting children about day-to-day matters in childcare settings; for example, what they would like to eat or drink, when they should go outside or when they need a rest. It may include other matters about how the organisation of the setting impacts on them, but it would be unusual to go beyond issues of immediate concern to young children themselves, which I believe is the issue that we are for the most part talking about.
	We have given a clear assurance that the statutory guidance supporting the outcomes duty, under Clauses 1 to 5, will carry forward the commitment to listen to children. The issue is also a key feature of the early years foundation stage, which will emphasise the importance of professionals listening to all young children in their care and is in line with the current routine approach to early learning. Indeed, we have already rolled out nationally training on the Coram Listening to Young Children: a participatory approach materials, specifically to encourage early years practitioners to seek and act on children's views.
	But, as I explained in Grand Committee, while the views of children aged under 5 are important and essential to service delivery, our difficulty with Amendment No. 6 is that it would place a duty on local authorities to consult young children about the strategic planning of services. As the noble Baroness, Lady Morris, just mentioned, there are practical difficulties in engaging this age group in meaningful formal consultation on issues such as where children's centres should be located or whether parents are able to use the type of childcare that they prefer.
	My officials have met with the National Children's Bureau and have explained why an amendment in this form cannot be accepted. We have given a commitment to work with it between now and Third Reading to see whether we can find a form of words that avoids the difficulties of the current amendment, while providing a meaningful proposition that meets the aims that we all share in terms of consultation with children under the age of five. I hope therefore that the noble Baroness will allow us time for that further work and will withdraw Amendment No. 6.
	Amendment No. 14 would place in the Bill a list of groups that local authorities must consult when carrying out their assessment duty under Clause 11. Let me stress again that we are agreed on the objective that she wishes to achieve. It is right and proper that key groups are consulted and involved. I can give a firm commitment that we will address that issue in the secondary legislation and guidance which will follow the Bill.
	The policy paper on the childcare sufficiency assessment duty, which we made available to Members of this House before Easter, makes a clear commitment that local authorities will conduct a thorough analysis of the childcare market in their area, identifying demand and matching that against supply in order to ascertain where there may be gaps and how these can be filled. Regulations and statutory guidance will set out what local authorities will need to do in order to achieve that. We have given a clear commitment that local authorities will have to consult parents, carers, children of all ages, providers, employers and local organisations to ensure that provision meets their needs. I hope that that provides suitable reassurance of our commitment to this cause.
	However, we are concerned that local authorities should have a duty to consult widely. We wish to pursue that matter in secondary legislation so that we have a full and complete list of people covered in that guidance. The list in Amendment No. 14 is a partial one. Most obviously it does not include children from the ages of five to 14 or disabled children up to the age of 18, and it does not also mention stakeholders such as employers or schools.
	We have given commitments in regard to particular groups that will definitely be specified in regulations, but the full list, which will be more extensive than the indications we have given so far, will be developed in partnership with local authorities and other stakeholders and will take into account views expressed during the consultation on the regulations— including, I should stress, the views expressed by the noble Baroness in this debate and in the debates in Grand Committee. In the light of those reassurances, I hope she will feel able to withdraw her amendment.

Baroness Walmsley: My Lords, I thank the Minister for his reply. In responding, perhaps I may first assure the noble Baroness, Lady Howarth of Breckland, that I did not intend to give the impression that I thought she was against consulting children. I was just pointing out that she reminded us that this is not a straightforward matter and that it will require highly trained professionals if it is to be done properly and in a meaningful way.
	The Minister referred to the guidance for Sure Start and children's centres. That is all well and good, but we need the voice of the child to be specified for everyone—for local authorities and for all settings other than Sure Start. The early years foundation stage is, of course, related to the day-to-day interactions between children and their care, but Clause 3 refers to the planning of early years provision and, as I mentioned in Grand Committee, I think young people can make a meaningful contribution to such matters. They could, for example, say that they do not want to have to walk through threatening areas in order to get to their childcare; that they do not want to have to go too far from their homes; that they want their parents to be able to choose when to access childcare and so on. I think it is perfectly reasonable to ask young children, in general terms, their views on that kind of thing.
	For those reasons, I very much welcome the Minister's commitment to continuing to work with the National Children's Bureau up to Third Reading to consider whether appropriate wording can be found to replace the wording in my Amendment No. 6. I think him very much for that.
	As to Amendment No. 14, I accept that it is only a partial list. I thank the Minister for his reassurance that a full and comprehensive list, along with guidance about how it should be implemented, will be introduced. That is a most satisfactory response and I am most grateful to him for it. For those reasons, I beg leave to withdraw the amendment.

Baroness Morris of Bolton: My Lords, the amendment seeks to insert the few, carefully chosen words,
	"Where local financial resources permit",
	at the start of Clause 6(1), which outlines the new statutory duties on local authorities to secure the provision of sufficient childcare to meet the requirements of parents in their areas.
	At Second Reading and throughout Grand Committee, Members on all sides of your Lordships' House raised concerns regarding the resources to support the ambitions of the Government in this Bill. The Minister has informed us that by 2007–08 spending on early years provision and childcare will reach £1.8 billion, which is almost double the 2004–05 figure and presents an average real annual increase of 24 per cent.
	A breakdown of this spending for early learning and childcare is as follows: £1.8 billion on Sure Start centres for 2007–08; £250 million on the transformation fund over two years, 2006-08; and £840 million over 2003-08 on extended services in schools. Of course we recognise that there is not an endless pot of gold. However, for the Government to ask local authorities to achieve so much is not realistic or fair. For example, the proposed funding for Sure Start breaks down to roughly £250 per child—not a huge amount, and not much at all when compared with the figure of just under £2,500 per child which was given in the first generous allocations between 1999 and 2002, and £1,300 per child, which was being spent in 2004.
	The Explanatory Notes say:
	"The proposed duties on local authorities in England will be financed within the resources which have already been made available to them for childcare and early childhood services".
	The LGA has raised serious concerns and said that there is a question around whether the dedicated resources will be sufficient to carry out these duties effectively and in the manner that the Government envision. The LGA also raises concerns about the future sustainability of these resources and the Government's commitment to building on the gains being made.
	The charity 4Children has estimated that in delivering the Government's own commitments, it is much more likely to require funds in the region of £13 billion by 2010-11. This is a doubling of the existing total government investment, including maternity support, early education, Sure Start and the childcare element of the working tax credit.
	The Government tell us that the new duties in the Bill involve no new spending pressures on local authorities. Yet children's groups and the LGA have all stressed that without extra investment, meeting these duties will result in making childcare even less affordable to parents or place additional and unacceptable pressures on council tax bills, particularly as some significant elements of the childcare strategy, where delivery is planned for 2008-10 are, I understand, as yet unfunded. I beg to move.

Baroness Howarth of Breckland: My Lords, I have spent a lifetime trying to deliver services in the statutory and voluntary sectors. When I read the Childcare Bill initially, I was excited by it. I was totally sceptical about the Explanatory Notes saying that it would have no impact on the financial needs of local authorities. I cannot square the needs that are expressed in terms of the provision that we are hoping to make with that phrase. Therefore, I add my concern to that expressed by the two noble Baronesses.
	It is quite clear that the Government have put huge resources and commitment into childcare, and on that I congratulate them and stand with them. But there is a conundrum here, as there is in a number of services; you have only to look at the health service and the issues surrounding it. As you pour money into services, the demand for qualifications, training and better quality care becomes apparent. For a long time, my noble friend and colleague, Lord Listowel, has pressed the issue of training in this sector. I felt that I must raise it under this amendment as I could not see where else to do so. This is the conundrum. We still have one of the lowest levels of qualification for childcare workers in Europe. To improve that will require funding over and above what seems possible.
	I do not feel critical of the Government generally in this; it is a reality about the public purse. But I do hope that the expectation will not be set in the outside world that every family will, by right, have a childcare place and then for that reality not to be provided and the local authority social worker or care worker being the one who actually has to take the rap for not being able to deliver the services on the ground.

Lord Adonis: My Lords, we accept, as King Lear told us a long time ago that,
	"nothing will come of nothing",
	and unless there are resources it will not be possible to deliver any of these services on the ground. However, significant additional resources have been put into the system in respect of under-fives provision, about which I will have a little more to say in a moment. I do not believe that we stand guilty of not seeking to provide very substantial additional funds to meet the need to provide additional services. We have put our money behind our commitments in this area.
	However, in terms of the specific amendment moved by the noble Baroness, I draw the attention of the House to the current drafting of Clause 6. It states:
	"An English local authority must secure, so far as is reasonably practicable, that the provision of childcare (whether or not by them) is sufficient to meet the requirements of parents in their area who require childcare in order to enable them . . . to take up, or remain in, work, or . . . to undertake education or training".
	I stress the opening words:
	"An English local authority must secure, so far as is reasonably practicable".
	The requirement is qualified by the words,
	"so far as is reasonably practicable",
	which has the effect of enabling local authorities to consider—as indeed they must—their own resources when determining how or whether to secure particular childcare. The current drafting gives local authorities a proper discretion to balance their duties with their resources, but it does not give them a right to take no action at all to fulfil a childcare duty. I would have thought that that would be as the House would wish the position to be.
	Local authorities' effective use of the resources available to them will of course be the key to the successful implementation of their duties, and the resources available are considerable. By next year, 2007–08, Sure Start spending will reach close to £1.8 billion a year, almost double the figure in 2004–05. As I said earlier, the resources available in respect of the commitment to free nursery provision for three- and four-year-olds has risen by 500 per cent since 1997. As part of the £1.8 billion, we have allocated funding to local authorities through the general Sure Start grant over the financial years 2006–07 and 2007–08 to help them prepare for the new duties placed on them in the Bill.
	I also stress that local authorities have a strong track record in developing and managing the childcare markets. This builds on their pivotal position with regard to children's services under the Children Act 2004. Local authorities welcome the leading role that they are now playing. They recognise that they are much better placed than central government to understand and respond to local needs. The new duty in the Bill underpins that work and draws it together more strategically, formalising arrangements.
	The total resources available for childcare in a local area are in any case significantly greater than just those of the local authority on its own. The noble Baroness referred earlier to the Prime Minister's remarks on 16 May. I am happy to quote more of those remarks, in particular his commitment which underpins what we will be discussing later in respect of the private, independent and voluntary sectors in the provision of childcare. The Prime Minister said:
	"We need to make full use of the voluntary and third sector, some of whom have greater expertise than the organs of government do".
	I thought that the noble Baroness would welcome those words because they so clearly mirror what she has been saying to us all the way through these debates and which I have strongly been supporting.
	Of course, the contribution made by those who support the voluntary and third sector is over and above the resources made available by the local authority. So the total resources available for childcare in a local area are significantly greater than just those of the local authority on its own.
	Therefore, in view of the fact that we have already qualified the duty in Clause 6 to make it a duty to secure childcare so far as is reasonably practicable, I hope that the noble Baroness will not feel the need to press this amendment. If she added the additional word that she suggests, it would be possible for a local authority to do nothing whatever to improve the provision of under-five services in its area, and I do not think that that is something that she would wish to see.

Baroness Morris of Bolton: My Lords, I thank all noble Lords for contributing to a very useful debate. I am sorry that I did not propose this amendment in Grand Committee, although I mentioned several times the pressures that local authorities thought that they would find themselves under. I hope that the Minister will recognise that I acknowledged when I moved the amendment the significant sums that the Government have invested in childcare. I thank him for his reply and very much welcome his remarks on the voluntary sector.
	There are some big issues here, however. Without resources, will "reasonably practicable" mean minimal? We must be very careful about that. I understand that if I pressed the amendment to a vote, which I am not going to do, it would mean that some local authorities could do nothing. That is not in anyone's best interests. But it is very important that we do not set local authorities up to fail and equally important that we do not let them get away with doing the minimum. The noble Baroness, Lady Howarth, was absolutely right—and the noble Earl, Lord Listowel, who is very keen on training. The whole of child development depends on services of high quality, which will depend on training. That is something that must happen.
	I end by saying that the Government's favourite think tank, the IPPR, has a paper out today called Equal Access? Affordable and appropriate childcare for every child, which also says that without significant additional investment, the Government will be unable to ensure equal access to affordable, appropriate and high quality childcare and early-years service. I beg leave to withdraw the amendment.

Baroness Walmsley: My Lords, my amendments in this group are Amendments No. 10, which relates to workless households, and Nos. 11 and 15, which relate to quality and suitability.
	Amendment No. 10 would add to the duty of local authorities to have regard to childcare provision for workless households, subject to adequate resources being available. I accept that the Government's main focus in the Bill, as clearly outlined by the Minister in Grand Committee, is providing childcare so that parents can go out to work and take the family out of poverty. That is all well and good, but my main focus is on the child's best interests. In that case, you have to remember that the children of workless households can also benefit greatly from good quality childcare. Indeed, given the stresses and strains of life in such households, they may well benefit more than other children.
	If some parents either choose to stay at home or have heavy caring commitments to either a disabled child or an elderly relative, it is not right that the other children in the household should lose out by not having their needs catered for. Government Amendments Nos. 16 to 18 emphasise the needs of disabled children, but other children in the same households are often very disadvantaged, and if their parents do not go to work, the Bill ignores them.
	Addressing the needs of such families is very cost-effective. We know that having a break from child-caring can improve parents' mental health. That could save costs on the NHS. Access to appropriate childcare is a cost-effective form of support, and may prevent the family reaching crisis point, possibly resulting in a residential placement. Having the opportunity to associate with their peers is vital to the development of children's social skills, as evinced by the EPPE project and other studies. If the Government want to reduce inequalities—the prime objective of the Bill—they should start with the children of workless households.
	Amendments Nos. 11 to 15 would introduce the word "quality" into the duty in different ways. My Amendment No. 11 was No. 28 in Committee, and somehow the word "must" in Amendment No. 28 has become "may" in No. 11 today. That is a mistake, and I am not quite sure how it happened. My intention is that local authorities must have a duty to have regard to quality.
	Amendment No. 11 also introduces the concept of suitability for the communities in the area. I will not repeat the arguments I made in Committee about the need for settings to have regard to the child's cultural needs and his ethnic persona. Part of the objective of good quality early years learning is to help the child develop his sense of self, and to interpret the world around him in relation to that self. If the child has no role models among the staff, or the setting takes no regard of his particular culture or persona, that is not in the best interests of that child.
	In this country we have many cultural communities: White, Black, Arabic, Travellers, Jewish and eastern European, and many different religions. It is vital that settings make the effort to recruit and train staff from all these local communities, or, if that fails, that they at least have regard to the child's needs in that respect.
	I hope that the Minister will have regard to the strong feelings of the House on quality. All the studies show that good quality childcare benefits children, and bad quality childcare harms them. The Government have shown their commitment to the right kind of care in many ways, including the development of the early years foundation stage. It seems more than surprising, therefore, that the word "quality" is absent from the Bill. There is a strong feeling in the House that it should be included somewhere in the Bill, as a matter of principle. Guidance is not good enough. As we said earlier, the Bill should contain reference to the principles underpinning the legislation. The word "quality" is another of those underpinning principles, which is why we have returned to it on Report. I hope that the Minister has moved on a bit about this since Grand Committee and can reassure us further.

The Earl of Listowel: My Lords, before speaking to Amendments Nos. 31 and 32 in my name, I express my shared concerns about quality. The Minister referred to the EPPE research, which focused principally on the over-threes. The NICHD research in the United States, which looked at the under-threes, found that there was a significant increase in aggressiveness among children who had prolonged exposure at a very young age to poor quality childcare. Those are the three main factors.
	Professor Melhuish is one of those charged by the Government with evaluating the Sure Start programme. In his estimation, the American research underestimates the impact of poor quality childcare on the development of the youngest children. Certainly, from the point of view of the work of the Oxford Parent Infant Project, I would think that there will be considerable concern about poor quality childcare for the under threes. Having said that, I recognise the benefit of good quality childcare to many children, especially the over-threes. I strongly support what the Government are doing with their childcare workforce development programme, which is welcome. One might not wish to be starting from where we are, but the Government are trying hard to move forward on the agenda of improving the workforce.
	Amendment No. 31 deals with the closure of settings in regulations for the purpose of staff development. That might be once a month, in an evening for two hours, to permit staff non-contact time to discuss with their team the children's welfare. Amendment No. 32 permits regulation on staff supervision, which would permit regular, individual, one-to-one mentoring of staff by senior practitioners. I thank the Minister for the interest that he has shown in my concerns in this area and for the opportunity to discuss this with him outwith the Chamber. The purpose of speaking to the amendments is to allow him the opportunity to place on record the assurances that he gave me earlier.
	Why is support for staff development important? First, we have in earlier discussions recognised that the key person approach is fundamental to the emotional well-being of under-threes and is important to older children in these settings. It is well recognised that good supervision of staff is important for the proper implementation of that key person approach. Unfortunately, many staff entering these settings may carry with them baggage from their own childhood. They may have experienced neglect or other difficulties, and there is always the danger, as anyone experienced in this area will tell you, that they may play out some of those earlier experiences on the children that they care for now. Good support to such staff is important in preventing that happening.
	Such mentoring support and supervised staff work discussion groups is probably the best training that staff can receive because it is all targeted on their experience and on reflection with a senior practitioner about what they do day to day. There is no risk of irrelevant training.
	There is also an important economic benefit. In a setting with 60 places for children, the staff costs might be £250,000 per annum. There is a high rate—about 10 per cent per annum—of staff absences through sickness in the sector. There is plenty of evidence that good supervision and support for staff can significantly reduce such absences. If it were to halve their number, that would be a saving of £12,500 per annum, which could then be used to pay for that proper staff support.
	Across the social care world, individual mentoring of staff or a staff team discussing the welfare of their children together is absolutely normal and expected. I was grateful to the Minister for the assurances that he gave me on the matter. How will he make clear the importance of staff in the early years foundation stage having that time away from the children for individual supervision or staff team discussions? The Government's transformation fund is their special investment in the training of staff to bring them up to a higher level. Can he assure the House that in the guidance on the fund's expenditure it will be clear that, for instance, staff might be given time and a half to attend work discussion groups and the monthly staff meeting, which takes place after work, and that such continued professional development will be accredited, so that the funding can be used for that important part of the support of staff? Finally, is the Minister considering how Ofsted might be encouraged to look at staff development and support? It does not currently and it might well need additional resources to do so, but it might be helpful if it did. The Commission for Social Care Inspection inspects in that area in its work in, for instance, children's homes.
	I recently spoke with a clearly troubled young woman who was going to start a career in childcare. That is a common experience for those involved in working with vulnerable young people; young people who have experienced neglect often wish to go into the social care world or to work in caring for children. They can bring a special commitment and insight to that work, but definitely need to be well supervised and supported if they are to be successful—to thrive in their work and to give good care to the children. I look forward to the Minister's response.

Lord Adonis: My Lords, noble Lords have been concerned that the duty in Clause 6 could somehow lead to a dilution of quality in childcare provision. There is no intention whatever to dilute quality. Indeed, all the measures that we have in place on childcare seek to improve the quality of provision generally. On the sustainability of funding, which was mentioned by the noble Lord, Lord Northbourne, I cannot give a commitment on the precise levels of funding that we or a future government would provide in spending reviews. However, we will certainly not be reducing the base-line outlays that have already been made available for the core under-fives provision. I think that that gives local authorities and providers for the under-fives capacity to recruit on a long-term basis. That course is essential to underpinning quality.
	As I explained in Committee, provisions and levers are in place to ensure that the quality of childcare is not compromised. These include the early years foundation stage which will set out a single framework for high-quality childcare from birth up to age five. The consultation on EYFS, which was published after the Grand Committee and I have made available to noble Lords, sets out clearly the quality standards that we expect providers to meet and against which Ofsted will inspect. For provision for children over the age of five, the Ofsted childcare register will also require providers to meet specific quality standards, including staff qualification levels and adult-to-child ratio requirements.
	Putting such a requirement in Clause 6 would not only duplicate the existing role of Ofsted—a duplication which would be undesirable—but return us to the position before Ofsted took on the role of childcare inspection in 2001, when each local authority made its own judgments on quality and standards were not consistent across the country. We have taken this approach precisely to ensure uniform national standards through the early years foundations stage and through Ofsted—the national inspectorates' duty to inspect—rather than leaving it to the discretion of 150 separate local authorities nationwide.
	In addition, the assessment of sufficiency of childcare that local authorities will be required to carry out under Clause 11 will not only assess parents' requirements regarding the quantity of childcare but also look at the quality of that childcare. The regulations and guidance underpinning the duty in Clause 11 will make clear that local authorities must consider the types and features of the childcare that parents require. The link in Clause 6 to parents' need for childcare that is eligible for tax credits also reinforces the local authority's responsibility to secure sufficient availability of quality childcare, because only childcare that adheres to the standards for registration by Ofsted will be eligible for tax credits.
	Amendment No. 15 seeks to require local authorities to have regard to quality when undertaking the assessment process. Some weeks ago I circulated to the House a policy paper on the duty to assess the childcare market which makes clear that local authorities will have to assess parents' requirements for childcare and compare that to the current availability and suitability of childcare in order to identify the gaps that need to be filled.
	On the subject of quality, I entirely accept all that the noble Earl, Lord Listowel, said about the vital importance of high-quality and continuous training of those in the under-fives workforce. His Amendment No. 31 seeks to give the Secretary of State power to require all childcare settings to close on a regular basis for protected time for staff development. His second amendment would give the Secretary of State power to require that all staff in childcare settings have staff development opportunities. We are extremely sympathetic to the objectives of both amendments. In particular, we would seek to ensure through all that we are doing that the second objective is met—that staff in childcare settings have development opportunities. Staff are the key factor to ensuring that children's experience is of the highest quality. I therefore entirely share the noble Earl's ambition to secure clear opportunities and time for staff development and adequate supervision.
	We share the amendment's objective of having professionals working together and being able to develop their practice together—the amendment's aim in providing for the closure of settings. We strongly share that objective, which is set out in The Early Years Foundation Stage. For example, one of the requirements, on page 13 of the document, is that:
	"Providers must be proactive in developing effective partnerships not only with parents, but with other carers, settings, and practitioners important to the child".
	Elsewhere, the document states:
	"Schedules, routines and activities must flow with the child's needs, with practitioners planning for individual children using sensitive observational assessment".
	So it will not be possible to deliver EYFS effectively without practitioners spending time together to reflect on both the progress being made and the needs of individual children. Good settings make time for this routinely, including the Thomas Coram Centre—the noble Earl brought its director to see me—and all settings will have to meet these requirements. As I explained to the noble Earl when we met, we intend that the guidance that we put out, including a CD-ROM that we are developing for the benefit of leavers from under-fives settings, will set out the best practice available in this area so that all settings can learn from it.
	When Ofsted inspects, it also has to make an assessment of the quality of the leadership and management of a setting and how that contributes to outcomes for children. Clause 50(1)(d) explicitly states that this will be carried forward into the new system, requiring reports to include information on,
	"the quality of leadership and management in connection with the early years provision".
	When Ofsted inspects provision, it talks extensively to the practitioners present and the manager, and these conversations include the subjects of supervision and support—for instance, what the manager does in order to help staff to improve. That will be part of the Ofsted process as well.
	When we come to develop the EYFS materials that we put out to early years settings, we will want to make references to the supervision of staff and training, and we will seek to ensure that they are in place. However, it may not be appropriate to use a simple measure of non-contact times. As I believe the noble Earl recognises, that could be one of several good-practice ways of meeting the needs of staff. He knows, because we discussed this in the context of the Thomas Coram Centre, that a very long process of preparation and consultation took place in that centre before it established its arrangements for staff training, including—I thought that this was telling—the provision of crèche facilities so that parents of children were not left with no provision whatever when the main professional staff were engaged in professional development. The noble Earl accepted that it is important that those arrangements are in place so that the provision of development opportunities for staff is not at the expense of parents, who, of course, these settings exist to serve.
	I mentioned the transformation fund in our earlier debates but this is the first time that it has been mentioned on Report; it appeared continuously in Grand Committee and I am sure that it will make many more appearances in future discussions. From that fund, the £250 million that is available between 2006 and 2008 is a key part of our policy to raise the quality of provision. Elements of the fund may—I stress this in response to the noble Earl—certainly be used to support development time. The quality premium of £5,000 per setting per year is to be awarded to full daycare settings employing or recruiting graduate level professional leaders. At least half of this is to be spent on continuous professional development for all staff in such settings, with a particular focus on preparing for the early years foundation stage. That fund, too, will help to support professional development.
	I should stress that settings will be free to use that funding as they wish so long as it meets overall staff development aims. That may well include, for example, paying staff who attend meetings set aside for staff development after normal working hours. We are clear that decisions on how to spend the quality premium must be left to local discretion.
	I turn to Amendments Nos. 8 and 12. Clause 13 gives local authorities duties and powers to provide information, advice and training to childcare businesses, to help them to be of high quality and sustainable. The statutory guidance that we publish under that clause will reinforce those points and will remind local authorities that it will often be more cost-effective to sustain existing provision than to launch a new provider, and it will also help quality standards to be reached.
	Moving on to the subject of accessibility, in Committee the noble Baroness, Lady Morris, raised some specific concerns on the issue of transport. I understand that for many families, particularly those in rural communities, transport and accessibility are crucial factors in deciding whether to use childcare. In meeting their duties under Clauses 6 and 11, local authorities will have to consider, and put in place, the most effective ways of securing childcare. They will have the flexibility to provide transport—for example, a village bus to take families to providers—if they feel that that is the most appropriate way of meeting local needs. I make it absolutely clear that if childcare is not accessible, that is not sufficient under the terms of the Bill and, as such, local authorities will not be fulfilling their legal duties.
	I turn, finally, to the issue of affordability, which I know has been a key concern of noble Lords on all sides of the House. Putting the word "affordable" into the Bill could be interpreted in a number of different ways and would mean different things to different families. Many factors need to be taken into account when assessing affordability. These can include family income levels, the age of the child, different work patterns and personal preferences, as well as the costs to providers of running sustainable childcare businesses, and those factors will vary according to local circumstances.
	I am sure that the way we have set out the duty in Clause 6, requiring local authorities to secure sufficient childcare which is eligible under the childcare element of the working tax credit, addresses the issue of affordability consistently across the country. In 2005–06, the level of investment in the childcare element of the working tax credit was more than £2.4 million a day, benefiting 356,000 families. Tax credit levels increased again this year, which means that the maximum proportion of childcare costs that parents can claim back has risen from 70 per cent to 80 per cent.
	In addition to subsidising the cost of childcare through tax credits, this Government also provide 12.5 hours a week of free early education and care for all three and four year-olds, irrespective of the employment or financial status of their parents. There are, of course, areas such as London where the cost of childcare is particularly high. That is why we are undertaking a pilot programme with the London Development Agency and the Greater London Authority to deliver an additional 10,000 childcare places for families on lower incomes.
	Amendment No. 10 would require local authorities to have specific regard to workless households when considering the sufficiency of childcare provision within their area—a concern of the noble Baroness, Lady Walmsley. As my noble friend Lady Crawley made clear during Grand Committee, high-quality childcare can make an important and valuable contribution to improving the outcomes for all children, including those in workless households. Although we entirely sympathise with the intentions behind this amendment, we believe that we are already doing a great deal to improve the outcomes of children in workless households. Given all the pressures of costs and the other duties that we are placing on local authorities, we do not believe that this would be an appropriate new duty to impose on them.
	Perhaps I may quickly summarise the steps we have taken that will benefit workless households. First, there is the existing duty to secure sufficient free nursery provision, to which I have already referred. All three and four years-olds are entitled to that provision, regardless of whether their parents are employed. Secondly, the introduction of the early years foundation stage will deliver high-quality integrated education and care in early years provision for all young children.
	Thirdly, the childcare duty already includes the need to secure sufficient childcare to enable parents to "take up work"; it does not relate only to those who are employed. For many workless households—particularly those headed by lone parents—the availability of suitable affordable childcare makes a key difference in the decision on whether to return to work, but this is covered in the current wording of the Bill.
	Fourthly, in assessing demand for childcare, local authorities will need to look at the complete picture. In order to identify gaps in childcare that are obstacles to employment, authorities will be under a duty to consult parents as part of their assessment of the market in their area—a duty which will be set out in regulations under Clause 11. Statutory guidance will make it clear that it will be vital to include unemployed parents as part of the consultation on how local authorities will meet their duties under Clause 11.
	Where there are gaps in provision that local authorities believe they should seek to fill, including gaps in provision of childcare for workless households, Clause 8 provides local authorities with all the powers necessary to support childcare provision in any way that may be needed to fill those gaps regardless of whether they relate to workless families or other families. I hope I have provided sufficient reassurance to the noble Baroness and that she may feel able to withdraw her amendment.

Baroness Howarth of Breckland: My Lords, I thought that, in terms of the local authority having a responsibility for strategic planning in the development of childcare places, this was one of the things that the Bill was going to put right. Indeed, in Grand Committee I raised my concerns about schools not being part of that strategic planning and therefore being able to develop services on their campuses outside and causing this kind of difficulty. I had all sorts of reassurances from the Minister on that and I look to the future to hope that that works through.
	I speak as an ex director of social services so I know about the temptation to provide your own services. It can be extraordinarily difficult for the voluntary sector in an area where something grand like a children's centre is planned. Some services will close and there will be turnover. I am sure the Minister will tell us in his reply that that happens and that there are some services which are not of the quality that we would wish. It is crucial that the local authority takes that strategic planning very much to heart. I would be interested to know how Ofsted, or whoever is going to take over the responsibility for the Commission for Social Care Inspection, will look at that broader programme of services on the ground and ensure that it meets the needs of children, as outlined so ably by the noble Baroness, Lady Walmsley.

Lord Adonis: My Lords, when the noble Baroness moved the same amendment in Grand Committee, she raised three particular concerns, which she has reiterated this afternoon. First, given rapidly changing demographics, especially in relation to working patterns, there might be an expectation that local authorities would become—and she used a graphic phrase—"crystal ball gazers".
	Secondly, the noble Baroness was concerned that overheads and financial pressures differed between the public, private and voluntary sectors and that a level playing field might not be operating, making the sustainability for private, voluntary and independent providers more difficult. Finally, she was concerned that new, heavily subsidised childcare might be created at the expense of existing good quality provision, which again she has reiterated with particular reference to the case of Reading local authority. I am afraid that I have not come equipped with briefing on Reading, although I will note carefully what she says about it in Hansard and reply to her with any knowledge we have about the specific instance. Indeed, I might even invite the local authority to comment on what she has said. Since she has made remarks about its policy in this area, it is important that it should address any concerns.
	I will deal with each of these issues in turn. First, on the issue of future changes in demographics and working patterns, I stress that we do not expect local authorities to become "crystal ball gazers", in the sense of having their eyes ever fixed on changes in the future and not firmly rooted in trying to provide for the present. However, we expect them, and we think that this is reasonable, through the assessment duty in Clause 11, to consult at least every three years—so they do not have to peer into the crystal ball that frequently—with the local community, which we define as local parents, prospective parents and childcare providers as well as employers, to establish not only the current availability and requirements for childcare, but also likely future requirements.
	That does not require them to make assumptions by themselves. It simply requires them, through the assessment process, to talk to people in their local area to find out which factors are likely to impact on the future demand for childcare. This could reasonably, for example, include talking to employers to find out whether they intend to expand their businesses and recruit additional staff over the following years, and talking to parents to establish what childcare they intend to use, or think they might wish to use, in the future. The authority would also be expected to take into account other demographic information like substantial local plans to build new housing. Often that may simply involve one part of a local authority talking to another to ascertain what its development plans are in a wider sense in its area and therefore to adjust its plans in respect of childcare accordingly.
	I cannot stress enough that the private and voluntary sectors are crucial to maintaining a diverse childcare market that is responsive to the needs of children. We wish to see their role properly respected by local authorities and, indeed, at every available opportunity. A few moments ago I cited the words of the Prime Minister, who could not have been clearer on the subject. I note that the statistics from our surveys of local authorities show that 58 per cent of childcare provision in children's centres is provided by the PVI sector, and that 82 per cent of children's centres have contracts with the voluntary sector. So there is no evidence of any widespread discrimination against the private, voluntary and independent sectors. On the contrary, all the evidence shows that local authorities of all political persuasions are seeking to engage with good quality private, voluntary and independent providers as a matter of course.
	In respect of nursery settings for three and four year-olds, there is also a very healthy diversity of provision. National data show that just over 20 per cent of four year-olds and 57 per cent of three year-olds take up provision from private, voluntary and independent providers. Overall, in 81 local authorities—which comprise 54 per cent of those local authorities for which we have returns—50 per cent or more of three year-olds take up their free entitlement in a private, voluntary or independent setting. So the evidence on the role of the private, voluntary and independent sectors is good.
	We recognise that closures have been an issue. This has been a very rapidly expanding market in recent years and it would be surprising if there had not been a high turnover as a large number of new providers seek to enter the childcare market. I am glad to be able to tell the House that closure rates are today lower than at any time since June 2003. Since last March, both total closures and the closure rate of childcare places have fallen in each quarter.
	Our guidance on private, voluntary and independent providers could not be clearer. The code of practice on the provision of free nursery education places for three and four year-olds, which I have previously circulated to noble Lords, states on page 19:
	"Local authorities should fund both maintained and PVI sector providers delivering the free entitlement fairly, transparently and equitably".
	I stress those words: fairly, transparently and equitably. It also states at paragraph 10.5 on page 27 that local authorities should work in partnership with providers to,
	"ensure that parents have a choice from a range of maintained and non-maintained providers and ensure that parents have the information they need to make choices that enable them to balance work and family commitments while feeling confident in the quality of their provision".
	So we have fully recognised the role of the PVI sector in this area. We have backed it up with the strongest possible guidance to local authorities. We stand ready to consider particular cases where that is not being honoured. If any pattern of local authorities discriminating against private, voluntary or independent providers were to emerge, we would not hesitate to consider what further steps needed to be taken. However, at the moment, all the evidence that we have is of strong and constructive partnerships between local authorities and the private, voluntary and independent sectors. Frankly, local authorities would be mad to act otherwise as so much high quality provision is already in the private, voluntary and independent sectors and we believe that the concerns that animate the amendment have been met. I hope that the noble Baroness will feel able to withdraw the amendment.

Baroness Morris of Bolton: My Lords, I decided to retable this amendment because when I looked again at the Grand Committee debate, I felt that the Minister's response did not fully address the concerns raised—indeed, he fuelled them.
	The amendment would insert a new subsection into Clause 7 to specify on the face of the Bill that regulations outlining the prescribed description in subsection (1) regarding a local authority's duty to secure early years provision free of charge must allow for a degree of flexibility and choice for the PVI sector regarding the number of hours and total weeks they may provide as a minimum free entitlement. Paragraph (a) addresses the number of hours a day to be provided and paragraph (b) the number of weeks.
	The aim of the amendment is to discuss the interests of real parental choice, the diversity of childcare provision, and to explore the details between free places and subsidised places.
	From April this year, as a result of the 10-year strategy and following the publication of the DfES code of practice for grant funding of nursery education for three and four year-olds, some local authorities have required private, voluntary and independent providers to extend the minimum free entitlement from 33 to 38 weeks. Other local authorities are providing flexibility and not enforcing 38 weeks, as long as parents are informed that some childcare providers may offer up to 38 weeks and that funding would be pro rata.
	However, growing pressure is being placed on providers to extend the number of weeks; clearly, the current flexibility is temporary. PVIs would like the choice of how many weeks of nursery provision they offer above the statutory 33 weeks. They argue convincingly that that will provide diversity and real choice for parents who may wish to balance their work and family lives differently and not require such long childcare hours to their children because they want their children to spend more time with their families.
	In Grand Committee, I explained that many childcare settings simply cannot extend the weeks of provision because they rent premises on a fixed basis, share the community centre with other organisations and activities or because of staffing issues. From April 2007, the minimum free entitlement will be extended to 15 hours per week—namely, it will rise from the two current 2.5 hours per day to three hours per day. At the moment, many nurseries already provide three hours, but they offer the additional half hour for a top-up fee that reflects the cost dependent on the area. For many providers, it is only possible for them to offer the 2.5 hour daily, grant-funded sessions free and maintain a high quality of care because they subsidise these free sessions with the top-up fees from parents for three-hour sessions. Many providers fear that once the free entitlement is extended, without the flexibility of choice, they will not be able to subsidise grant-funded sessions and, as a consequence, many sessional settings will no longer be sustainable and will have to close. The result of that is that there will not be sufficient high-quality places for three and four year-olds—the exact opposite of what the Government claim they want to achieve.
	In his reply, the Minister only confirmed that fear when he read out paragraph 5.9 of the code of practice which stated that:
	"The Department recognises that some providers are not open for 38 weeks and may not be able to offer the full entitlement, particularly in the first year".
	I missed that phrase "in the first year" when the Minister replied in Grand Committee. I would hate him to think that I do not hang on his every word, but I missed that bit. This is only for one year and this year of transition will not address the fundamental problem that we need to maintain the choice of nurseries in terms of hours and weeks of operation and so provide real choice of parents. The Montessori Foundation has called this extension of hours a threat to the actual existence of small community-based nurseries.
	The Minister also said that if providers could not find appropriate premises they could simply move into the all-singing, all-dancing children's centres. I am afraid that that smacks of choice and diversity, but, as I said on the last amendment, only on the Government's terms. They should not be forced to move if they do not want to, particularly in light of recent statistics that call into question the wisdom of placing very young children in group care for long hours.
	I quickly raise a third issue. It has come to my attention that the DfES is sending questionnaires to nursery providers regarding costs focusing on day care providers. One nursery has informed me that it estimates that it will be £25,000 adrift in costs with these new provisions. Why did the department not carry out the survey before suggesting the implementation of such plans? I know that this is only one example, but it strikes right at the heart of the problem. Local authorities will have powers to ensure that all providers do not charge a top-up for places funded by the nursery education grant. However, there have been no guarantees that the level of NEG funding will cover the cost of providing a good-quality early years experience. We believe that parents should have a real choice of the setting that they wish to send their children to, a real choice in the hours of childcare that they want and the choice to pay a top-up fee should they be confident that that will provide them with a good-quality childcare place. I hope that the Minister will undertake to reconsider this issue and I beg to move.

Lord Adonis: My Lords, this amendment relates to the minimum free entitlement for three and four year-olds of 12.5 hours a week which, as the noble Baroness said, has been extended from 33 to 38 weeks in all settings. That will mean that children receive the same basic offer regardless of the setting that they attend. In the past, children taking up their free entitlement in maintained settings had typically received a funded place over the school year, which equates to 38 weeks, while those attending settings in the private, voluntary and independent sectors were funded for only 33 weeks. That meant that if you chose a voluntary sector playgroup for your child they would receive 62.5 fewer hours than if they were to go to a school-based provider.
	The changes that we have made are not only be beneficial for children but strongly beneficial for the providers themselves, especially those in the private, voluntary and independent sectors who will now operate on a level playing field and will receive funding for an equivalent number of hours provided. That will have the effect of offering parents more choice, which I believe is precisely the objective that the noble Baroness seeks to advance. Of course, we have ensured that sufficient additional resources have been factored into local authority funding to cover the costs of a 38-week place for every three and four year-old whose parents wish to access it.
	We know that some providers have said that local authorities are not providing sufficient funding to enable them to deliver the flexible free entitlement for three and four year-olds. I should explain that local authorities are funded in exactly the same way for places in all settings; there is no discrimination in funding between different types of provider. All three and four year-olds in an authority are funded from the centre at the same rate. But it is for local authorities to determine the most effective use of resources at local level. To remove that discretion to set the rate at which they fund places in the early years would run counter to the principles of local democracy and decision-making and be at odds with the rest of the education funding system.
	However, we make very clear in the code of practice on the provision of free nursery education places for three and four year-olds that local authorities should adopt a principle of equal and transparent funding at local level. The department will take seriously any allegation that a local authority has not had due regard to the code of practice, especially if this results in under-funding of some local providers so that they cannot sustain an extension of the free entitlement without cross-subsidy.
	The Government consulted widely last year on the changes to the free entitlement. More than 500 responses were received from a range of providers in the maintained and non-maintained sectors, as well as from local authorities and parents. The noble Baroness will be reassured that the respondents were supportive of the proposal now being implemented to level the playing field by ensuring that children in all settings would have access to the same basic 38-week entitlement. We do realise, though, that some providers, particularly, although not exclusively, in the first year, may not be able to offer the full 38-week entitlement. We expect local authorities to work with and support providers to extend their services to 38 weeks whenever possible. To this end, we have also made additional capital funding available to them through the general Sure Start grant. This should be particularly helpful to those small sessional providers who might be finding it difficult to secure the facilities to offer free provision over an additional five weeks of the year.
	I should stress, though, that the duty to ensure sufficient 38-week places is a duty placed on local authorities, not providers, and that the availability of provision in a local area should be delivered in accordance with parental demand. Therefore, as long as local authorities can provide sufficient 38-week places for those parents who want them, either through individual providers or in collaboration between providers, there should be no need for them to put undue pressure on providers to deliver places only over 38 weeks, when there is also a market among parents for a provision over a lesser period. We also acknowledge that some parents may take an informed decision to choose a provider that is open for fewer than 38 weeks. We have therefore made clear in the code of practice that in these circumstances providers should be funded for the free provision that they deliver. So it is not an all-or-nothing approach for the 38 weeks, even over the medium term.
	The Government's longer-term commitment will increase the free entitlement from 12.5 to 15 hours a week, which will take the benefits to children and families a stage further. It will allow parents the flexibility to access the entitlement in a way that responds best to their family circumstances, will be of educational benefit to children and will also give parents greater access to training and the labour market.
	That, however, is for the future. So far as the existing changes are concerned, we believe that there is flexibility for parents to make the choices they wish, and that that is properly reflected in support for providers. We believe that parents are the best judges of what is right for them and their children. We have no desire to nationalise either them or the providers, and I hope the noble Baroness will feel able to withdraw her amendment.

Lord Northbourne: My Lords, I rise to move Amendment No. 19 and to speak to Amendments Nos. 20 to 23, 29 and 35. These amendments are about the role of grandparents and other relatives of a child who provide care for the child. I have to say that it was a group of amendments that was difficult to draft. I have taken advice, and I hope the amendments I have set down will have the effect I intend them to. If not, and if the Government accept the principle that lies behind them, I shall be perfectly happy if the Minister decides to take them away and reword them. I intend, therefore, mainly to discuss the principle of what I am trying to achieve rather than discussing the detail of the amendments.
	I am attempting to create three distinct categories of childcare, so we can give some status to, and some clear understanding of the position of, relatives with whom the child does not reside but who provide childcare for him or her. The first category I envisage is professional childcare, a category provided for under the Bill and subject to regulation relating to the ratio of carers to children at each age, the training of staff, accommodation, syllabus and so on. As currently, the main purpose of the Bill is to secure the delivery of this kind of childcare in the quantities and of the quality required, and at an acceptable price. Providers and prospective providers will be given information, advice and training by the local authority and will be inspected by Ofsted. Parents will be able to claim tax credits in respect of this kind of childcare.
	The second category, at the other end of the spectrum, is childcare provided by parents or others with whom the child is living, to whom one can usefully refer as "surrogate parents". Under the Bill, parents, including surrogate parents, are to be given or have available to them information, advice and training if they ask for it. They will also be able to draw down childcare tax credits to help pay for any professional childcare they decide to use.
	There is therefore quite a strong indication by Government in the Bill that they intend to support this kind of informal caring activity.
	The third category is the kinsman—whether it be a grandparent or some other kin—with whom the child does not live but who is providing care for the child. Grandparents are the key example. This category of informal care is extremely popular with parents. Kinship care given by grandparents alone currently represents about 60 per cent of all childcare and is said to save the Exchequer £1 billion a year in terms of lower demand for subsidised professional childcare. Some 82 per cent of children get some of their care from grandparents, and nearly 5 million grandparents each spend at least three days a week caring for their grandchildren.
	My amendment does not suggest that grandparents and other kinship carers should be subject to regulations or to inspection. Like the Government, I believe that such a proposal would not be acceptable. Equally, I do not suggest that kinship care of this kind should qualify the parent to draw down childcare tax credit. I happen personally to believe that it probably should, but the political atmosphere is such that it is not feasible to suggest that at this stage. Perhaps we shall have to wait for a more enlightened government to put that through. The group of amendments does provide that grandparents and other kin who are offering this category of childcare are entitled as of right, if they ask for it, to advice, information and training from the local authority, which would enable them with more confidence to do a good job for their child. Such advice, training and support would only be given if asked for. As far as the state is concerned, the cost of providing information, advice and training would be offset by the reduction in professional childcare that would be needed because of better quality kinship care.
	Such advice, information and training would also give some status to kinship carers, thus encouraging grandparents and kin to realise that their contribution is both recognised and valued. It might help secure that more grandparents and kin would be willing to take on this work and be proud to do so. That in turn would offer advantages both to the Exchequer and to the child. Some degree of recognition of the contribution that grandparents and kin are making today and could make in the future would be entirely beneficial in terms of the well-being of the child, the parents and the Exchequer.
	Briefly, I should like to go through the amendments, because they are quite complex. Amendments Nos. 19, 20 and 21 would provide for an extra subsection in Clause 13(1) which requires a local authority in England to provide information, advice and training to a range of categories of persons. My amendments would extend the range of persons entitled to receive this advantage to all persons in the area who are providing or intend to provide childcare and have requested such information. The amendment would therefore sweep in the parents, grandparents and relatives who are giving care to a child. Clause 18(4) excludes certain categories of people from being providers of childcare and those categories include not only parents but all relatives. My Amendments Nos. 22 and 23 would restrict the provisions of Clause 18(4) to relatives with whom the child lives, so that non-resident relatives, including grandparents, would be entitled to the help provided for in Clause 13.
	Amendment No. 29 would exclude from the requirements to register,
	"any relative of the child who is providing early years' child minding for that child".
	Amendment No. 35 makes the same exclusion for those relatives providing later years' childminding. Therefore, this group of amendments would leave us with three categories of childcare; professional childcare, parents, including surrogate parents, who are provided for elsewhere in the Bill; and relatives, including grandparents, who would fall into a separate third category. They would not be required to register and would not be entitled to provide childcare that qualifies for tax credit, but they would be entitled to information, advice and training, if they request it, from the local authority. I beg to move.

Baroness Crawley: My Lords, we have had an interesting debate again on the amendments of the noble Lord, Lord Northbourne, on kinship care. I very much recognise the care with which he has tabled the amendments and put them into the three categories. I declare an interest as an enthusiastic grandmother, who can be found most Fridays in a certain park in London with a very lively 20-month grandson.
	Before I deal with the specific issues raised by this group of amendments, I wish to acknowledge and praise the hard work and commitment shown by the many thousand of relatives who undertake caring responsibilities, in particular grandparents. The noble Lord, Lord Northbourne, mentioned the percentage of relatives who carry out that caring work, and it is very much the cement in the system. I commend the Grandparents' Association and, indeed, the noble Lord, Lord Northbourne, for their tireless campaigning to ensure that grandparents and other relatives get the recognition and support that they deserve.
	Perhaps it would be helpful to set out the current position regarding relatives who provide childcare. As I said in Committee, the definition of childcare in Clause 18 is purely for the purposes of this Bill. It is not a comprehensive definition and it certainly does not prevent anyone else from caring for a child. There is nothing to stop a relative caring for a child, either formally or informally. Indeed, if they care for unrelated children as well, they can also be either registered childminders or approved child carers, provided that they meet the required standards. This is the case now and will continue to be the case once this legislation comes into effect.
	These amendments, taken together, have a number of effects. They would bring relatives into the Clause 6 sufficiency duty. This means that, by definition, local authorities would be under a legal duty to take care by relatives into account when securing sufficient childcare. That is not necessary, as the assessment process will already give local authorities an understanding of how much informal childcare is being provided, and that will have an impact on their subsequent plans to secure sufficiency of formal care.
	My understanding is that the noble Lord's intentions are, first, to ensure that anyone who cares for a child, whether through local authority fostering arrangements or private fostering arrangements, or, indeed, relatives or parents themselves, has the appropriate support and training to provide childcare and, secondly, to allow relatives voluntarily to register with the Ofsted childcare register, enabling parents to claim tax credits to help with the cost of that care. However, the noble Lord, Lord Northbourne, has now explained that he is not interested in the area of tax credits.

Baroness Crawley: My Lords, I have to say that there is not a meeting of minds between him and the Government on that issue.
	While I sympathise with the aims of these amendments, I do not feel that they are appropriate. First, I shall deal with the effect on the duty in Clause 13 to secure information, advice and training for providers. As I explained in Committee, local authorities already have general powers in Section 2(1)(b) of the Local Government Act 2000 that enable them to do anything which they consider is likely to achieve the promotion or improvement of the social or economic well-being of their area. So, local government is already able to provide support and assistance. That includes providing information, advice or training to help family members or other carers who look after children.
	In addition, there are also specific provisions for those fostering children—noble Lords have raised this matter—either privately or through the local authority. In the case of fostering that takes place through the local authority, private fostering agencies or voluntary organisations, standard 21 of our fostering services national minimum standards of 2000 already requires these organisations to develop strategies to work with and support carers. I hope that that gives some comfort to the noble Earl, who raised the issue. Those strategies should include arrangements for training and development, information and advice and assistance in dealing with other relevant services, such as health and education.
	I accept that, for relatives who are providing informal childcare, this does not equate to an entitlement to information, advice and training, which is being sought in the amendments. However, given that the services that we expect local authorities to secure under Clause 13 are mainly around business support and sustainability and registration processes, I do not think that it would be appropriate to require local authorities to provide such services to kinship carers.
	Local authorities are also able to use their Section 17 money—from the Children Act 1989—to provide services or assistance to support any child who is deemed to be in need. This is already happening in Kent, for instance, where the local authority uses Section 17 funding to help grandparents to undertake caring responsibilities.
	There has been some misapprehension about what we mean when we refer to parents. The Bill states that "parent" includes anyone who has parental responsibility for a child and anyone who has care of a child. I know that there is concern among noble Lords and those in the voluntary sector that this definition of parents does not include relatives who informally look after a child for longer periods. Let me make it absolutely clear that the services described in Part 1—the early childhood services, the childcare duty, the duty to assess childcare requirements and the information duty—will all be applicable to anyone who has full-time care of a child in place of that child's parents.
	As I made clear in Committee, our aim is to improve the outcomes and life chances of children, regardless of their family arrangements. That is why the duties set out in Clauses 1 to 4—to improve outcomes and to secure integrated early childhood services—apply to all children and their carers.
	A good example of services reaching out to extended family members is the grandparents' group in the Nunsthorpe and Bradley Sure Start Children's Centre. The group meets on a weekly basis in the community room of the children's centre and has an average attendance of between 10 and 15 grandparents—both grandfathers and grandmothers. The group often invites outside speakers to talk about topics such as diabetes and other health-related matters. Due to demand, the group also has a joint coffee morning every month with the younger parents who use the centre. This helps to integrate the groups and allows centre staff to meet three or four generations of the same family at once, giving every opportunity for important messages to be heard. Staff working at the centre have found that in order to influence mums it can be helpful to filter key information to grandparents and vice versa.
	Additionally, in assessing the childcare market, local authorities will have to take relatives into account in two ways. They will do so, first, by assessing how much childcare is provided by relatives so that they can gain a more balanced picture of their local childcare market and, secondly, where a relative is the primary carer of a child in place of that child's parents, by assessing that relative's requirements for childcare in the same way that they would for the natural parent. Equally, anyone who has care of a child will be able to expect that the local authority will, so far as is reasonably practicable, secure sufficient childcare to enable them to work or train.
	For clarification, that means that granny, grand-dad, aunt or uncle will be able to expect the same service from their local authority as a natural parent if they are looking after a child on a settled basis. Our guidance to local authorities on all these services will reinforce this message. This commitment to include everyone who has parental or care responsibilities is already evident in our recently published Respect Action Plan, which commits £70 million to support all parents and carers.
	In the light of my assurances to the House that relatives and foster carers will be able to have the same expectations as natural parents if they are caring for a child, I ask the noble Lord, Lord Northbourne, to withdraw his amendment.

Baroness Crawley: moved Amendment No. 39:
	Page 60, line 2, at end insert—
	:TITLE3:"Local Authority Social Services Act 1970 (c. 42)
	A1 In Schedule 1 to the Local Authority Social Services Act 1970 (social services functions) after the entry relating to the Children Act 1975 insert—
	:TITLE3:Adoption Act 1976
	Functions continuing to be exercisable by virtue of any transitional or saving provision made by or under the Adoption and Children Act 2002.""

Baroness Crawley: moved Amendments Nos. 40 to 42:
	Page 70, line 12, column 2 at beginning insert—
	
		
			  
			  "In the heading of Part 10A omit "England and"." 
		
	
	Page 70, line 23, column 2 leave out "In Schedule 9A, paragraph 8(1)" and insert—
	"In Schedule 9A—(a) in paragraph 1(1)(c), the words "the Secretary of State or", and—(b) paragraph 8(1)."
	Page 70, line 31, column 2 at end insert—
	"(za) paragraph 2(1)(a);"
	On Question, amendments agreed to.
	Clause 109 [Commencement]:

Baroness Neuberger: rose to ask Her Majesty's Government what is their response to recent reports by the Royal College of Psychiatrists for the Healthcare Commission and the Sainsbury Centre for Mental Health on in-patient care in acute mental health wards.
	My Lords, I am delighted to hear that we are to have longer for this Question. I do not know what to add to that, other than I am sure that the Back-Benchers will be delighted, and I presume that I have a little licence to go beyond 10 minutes—perhaps even to 11—although I hope that I will not need to do so.
	Like everyone else who is taking part in this debate—and, I am sure, the Government—a year on, I welcome the two reports to which I refer in my Question, as I have welcomed all the follow-up reports since, most of them making some of the main points. Along with those go the King's Fund's London's State of Mind, which came out in 2003, the Mental Health Act Commission's In Place of Fear?, not to mention, significantly, the report of the Sainsbury Centre for Mental Health, The Search for Acute Solutions, published earlier this year, in partnership with—we should all be delighted that this is so—the Department of Health, the Royal College of Psychiatrists, the Royal College of Nursing, the NHS Confederation and the College of Occupational Therapists. So people are working together.
	Before I go much further, I declare some interests. I am one of two advisers—the other is sitting diagonally opposite me—to the trustees at the Sainsbury Centre for Mental Health. I am the former chief executive of the King's Fund and I am the former chair of Camden and Islington Community Health Services NHS Trust, which had a large mental health component.
	There is a considerable amount of criticism in these two reports, but we also see a very mixed picture. Among the criticism is a comment concerning bed occupancy. Reports show that the bed occupancy rate was an average of 100 per cent; in London. the average was 107 per cent; but the Royal College of Psychiatrists' guidelines say that the ideal bed occupancy rate is 85 per cent. In my days of chairing an NHS trust, I remember that our bed occupancy frequently reached 120 or 130 per cent, which I was thought was terrible. Our patients would go away on leave at weekends or during the week and would come back to find that they had nowhere to stay. It was a truly appalling situation.
	That is important not only because it is overcrowding per se but it adds to the atmosphere of tension and violence in the air in many of the acute in-patient wards in the UK. To add to that, there are high levels of staff vacancies and staff turnover. The vacancy rate for qualified nurses was 13 per cent, but in London it rose to an astonishing 22 per cent. The average ward on any one day has two nursing posts vacant; it employs four agency or bank staff to fill gaps in the service; and staff in a quarter of the wards surveyed have to work unpaid overtime. In addition, half of all wards lack a lead consultant; 13 per cent have no ward manager; 12 per cent have no administrative support; and three-quarters have no housekeeper.
	To add to that, the reports suggest that there is far too much administration and paperwork for the nurses to do, at least partly because there is insufficient administrative support on the wards, and the physical environments are often poor. That is combined with what the patients—the service users—told the people who compiled these reports: time and again, they said that they were bored. Boredom is commonplace.
	Meanwhile, there is very little engagement between nurses and patients, and the staff generally do not feel competent to deal with the increasing numbers of patients with complex needs. That is particularly the case with those with dual diagnosis—a mental illness or disorder combined with an addiction to drugs or alcohol. The staff themselves complain that they are insufficiently trained and insufficiently skilled.
	In the national survey of 300 acute in-patient psychiatric wards for adults, commissioned by the National Institute for Mental Health in England and published by the Sainsbury Centre for Mental Health—the acute care report—it was found that most wards have single-sex sleeping areas but that 8 per cent lack separate bathrooms and 4 per cent lack separate toilets. On 7 per cent of wards, service-users' rooms have no natural daylight. That must be so horrible that I find it almost unimaginable, as many of the patients are there for a very long time. On 9 per cent of wards, the patients cannot control the lighting, which often means that the lighting is on at night when they are trying to sleep.
	Meanwhile, less than half of wards have quiet places to spend with visitors, and only 65 per cent have a safe place for visiting children. That means that 35 per cent do not have a safe place for visiting children, so children very frequently do not visit adult parents when they are in an acute ward.
	On race, when the Mental Health Act Commission, with the Healthcare Commission, undertook the Count Me In census of all acute wards on 31 March last year, it found that black, African and Caribbean people are three times more likely to be hospitalised with mental health problems than the rest of the population, but that once in hospital, black men are 50 per cent more likely to be secluded and 29 per cent more likely to be subject to physical control or restraint than white men. That adds to the air of violence in the wards.
	It gets worse. In the Royal College of Psychiatrists College Research Unit/Healthcare Commission's 2005 National Audit of Violence report we learn that one-third of service users, 41 per cent of staff and 18 per cent of visitors to acute units experienced violent or threatening behaviour. Meanwhile, Mind's 2004 Wardwatch survey found that 53 per cent of in-patients said the ward environment did not help their recovery, 27 per cent of patients felt unsafe in hospital and 51 per cent had been verbally or physically abused there. Most worryingly, only a third of those experiencing abuse reported it to a staff member. I wish to focus on that today. I know other speakers will cover some of the other areas of concern.
	What do we learn from these two reports? There is a clear picture of violence on the wards and a clear picture of boredom. The two are not unrelated. Working practices urgently need to be changed. We clearly need better staff training and more time for staff to engage with patients rather than doing administration which they should not be doing.
	On 31 May this year, the King's Fund held a conference and heard from three projects where it has been demonstrated that changes in practice could improve the experiences of patients and staff for very little financial input. They relate to the boredom and lack of activity syndrome. I draw one point to your Lordships' attention: protected engagement time, when the staff office is closed and the ward shuts down to phone calls, paperwork, visitors and other professionals for a specific regular time of day during which staff engage with those who use the services. We should not need to shut down wards in that way, but clearly we do. It has become very popular with patients who often feel they have no time with staff except when they receive their medication or when they are in a real crisis.
	There are many other initiatives—there is no time to go through them now—and there are wonderful people working with the patients. Many people in those reports have commented on the calibre of some of the staff, even though there are real staffing problems in many areas. At the launch of the violence audit, Paul Lelliott, the director of the Royal College of Psychiatrists' research unit, actually praised the staff and said:
	"Despite the problems illustrated by the Audit, we were struck by the dedication and enthusiasm of front-line staff of all disciplines and the extent to which they were committed to working with service users to improve safety".
	Projects that deal with boredom levels lead to a more relaxed atmosphere, better patient satisfaction, and a reduction in levels of adverse incidents and conflict on wards. People are to be praised for doing that. Staff also feel empowered by being given the opportunity to do that kind of thing and to help to design and innovate practice on the wards. They find networking—sharing with other staff in other wards and other places—enormously useful; that is a great way to learn and to share practice.
	That is for everyone in the acute sector, but when it comes to violence we should ask some very specific questions. Seventy per cent of staff report problems with dual-diagnosis patients, yet it is abundantly clear that good services, with a well trained and full complement of staff, can crack many of these problems. We know that detoxification is still a reason why some patients are brought in. One recommendation of the Acute Care report was that trusts should review the number of detox beds against the actual number of service users brought in, liaise with drug action teams locally, and form an agreement on appropriate admission to adult acute in-patient wards. As yet, there is no evidence that that is happening. Does the Minister have any evidence that that is happening, either in local pockets or nationally? They also recommended reviewing staffing levels, skill mix, quality of training and safety in view of the numbers being brought in solely for detox purposes, particularly when the beds are not ring-fenced for that. Again it would be good to hear whether that is happening.
	The Royal College of Psychiatrists is running an excellent accreditation programme for acute wards. It includes self-review against the guidelines, following with peer review and then validation and affirmation. Eventually, it will lead to full accreditation. The first tranche is some 19 wards, coming to an end in October. Applications for a second tranche are out to invitation. The question we should be asking, however—maybe the Minister can give us an answer—is why so few wards are, as yet, involved. How easy is it for staff to get away to engage with this kind of accreditation programme for acute wards when we have such acute staff shortages? The various reports suggest that it is hard to get away. Are the Government going to do more to push staff to get involved, and reward those who do so and do further training?
	Secondly, the National Audit of Violence has been going on since 1999; it is not new. The chairman and chief executives of trusts have to sign off a memorandum of understanding, so they must know what is going on and how it will appear. What will the Government do to encourage chairs and chief executives to get their staff into the accreditation programme and ensure that staff get the chance to be more innovative and less defensive in their practices?
	I shall shortly run out of time, so my last point is that Anna Walker, the chief executive of the Healthcare Commission, spoke at the launch of the National Audit of Violence. She said that the national audit had found that one in three users had experienced violence and threatening behaviour while in care, along with 41 per cent of clinical staff and nearly 80 per cent of nursing staff. She said:
	"These figures are deeply worrying".
	While acknowledging that is not easy to deal with, she said:
	"We must do more to protect the people who use and work in our mental health services. This audit gives us hard evidence on an area of growing concern. It suggests that while community services have been really important, more attention must be given to inpatients. Nobody must take their eye off this ball".
	This Unstarred Question is to ask the Minister whether the Government are seriously keeping their eyes on this particular ball.

Baroness Murphy: My Lords, I thank the noble Baroness, Lady Neuberger, for bringing these reports and this much-neglected topic to the attention of the House. It also gives me an opportunity to pay tribute to the work of the Sainsbury Centre for Mental Health. Our current national policy owes much to the vision, knowledge and persistent determination of that centre to demonstrate what really works. I have been proud to be a friend, supporter and occasional co-worker since the centre's inception 20 years ago.
	I declare an interest as a fellow of the Royal College of Psychiatrists, and chair of the strategic health authority responsible for the performance of two large mental health trusts in east London. That area generates the highest morbidity in serious mental health problems in the UK.
	Between 1987 and 1994, I visited more than 200 psychiatric in-patient units in England and Wales, in my role as vice chairman of the Mental Health Act Commission. That was almost all of them at the time, and I often visited several times. I sometimes got that "If it's Tuesday, this must be Claybury; if it's Wednesday this must be Rainhill" kind of feeling. My observation then was that the rot was already beginning to set in. New community mental health teams set up in the late 1970s and early 1980s had begun to take off in a big way. Mental health nurses, psychologists, OTs and psychiatrists—including myself—with any ambition or vision were leaving the wards in droves for the sort of work they felt they had trained for.
	Following that period, the Mental Health Act Commission produced a devastating report about life on acute psychiatric wards in 1998 and, since then, the situation has worsened; although, in my opinion, the past few years have seen a slight improvement. I shall not repeat all the criticisms of acute wards so evident in the reports that the noble Baroness, Lady Neuberger, has so eloquently described. I am not going to dispute any of those findings; if anything, the situation in London is much worse than has been described. There are shockingly poor physical environments, patient boredom and little engagement between nursing staff and patients. We have heard it all before, and I am afraid it is all too obvious as you visit wards.
	In London the admission of potentially violent and highly disturbed people adds a further complexity. In inner London, as we have heard, the dual diagnosis of psychosis and drug misuse is now the norm. No one in any state of mind would want to be on these wards. They are often unsafe and quite frightening. They are frightening to visit, never mind to work in.
	As a psychiatrist, I am often asked by friends and colleagues with mentally ill relatives if I can recommend a decent place to be admitted. In London, I am profoundly ashamed to say, I can never think of anywhere.
	The situation, in some ways, is that people are paying far more attention; but, in one way, one might expect pressures to get worse. It was thought that the new crisis resolution and assertive outreach teams would reduce admissions. They cannot do so at the moment because they are beginning to engage longer with people who used to get lost to the system—those at severe risk of being at the centre of an untoward incident. It will take some years before the economic and social benefits of the new ways of working will be seen. We will increase the admissions for a time as such people are picked up and maintained. We know, however, that patients already appreciate the difference in these services. That is reason enough to continue, but these will not for the moment reduce pressures on acute words.
	What are we to do about it? I do not blame any government for the situation that we are in, and I do not blame those who work on the wards for the situation they find themselves in. In fact, their heroism in continuing to work on the wards is sometimes quite remarkable. A lot of people are aware of the problems and most mental health trusts have tried various initiatives, although perhaps without sufficient adventurousness to make real differences. I have four brief suggestions. One is easy, others are perhaps less so than they might seem at first. Perhaps I can ask the Minister to respond to the ideas.
	The first is to create an integrated service in which community team and ward staff all rotate as one team and are managed under the same budget. That seriously encourages alternatives to acute ward care. The Norfolk and Waveney Mental Health Partnership NHS Trust has done much of this circulating of staff to ensure that people keep up to date and understand each other's work. Other units have tried joint management, but few stick with it. At present inpatient staff never get to know a patient or service user except in crisis and do not get to establish a relationship as the community team worker does. For the community team at the moment there are negative incentives to admit when an alternative residential care or day care place might be better. Budgets are institution bound and do not facilitate movement. Joint management prevents inpatient units being allowed to deteriorate physically while new community health teams get all the capital spend. You see all the time new teams being set up yet the physical environments being reduced.
	My second suggestion is that staff—and I think this echoes what the noble Baroness, Lady Neuberger, said—need to feel pride in specific therapeutic skills which enable them to treat people, and wards must be properly managed. Training for ward leadership is cursory; qualified nurses can suddenly find themselves managing 50 staff and a budget of £1.5 million without any training whatever. What nurses should do with their patients is often a mystery. They have control and restraint training but no education and specific training for therapeutic skills or behavioural training, interpersonal support skills, family interventions and so on.
	Then there are the other ward staff, who really should be organising activities on the wards. At the moment we employ hardly anybody with the right skills to do that. This is not an OT function and, given the youth and educational disadvantage of many patients, we really need teachers and sports or gym supervisors on our wards.
	Thirdly—my medical and nursing colleagues might not like me saying this—wards are still run on traditional hospital ward lines, and I cannot for the life of me see why they have to be run by nurses at all. We need nursing skills but wards could be run by bright people with all kinds of skills—social work and management are two examples. This has been done in learning disability services, for example, during the late 1980s, with great success. We are still too stuck in the traditional model of nursing care, which has been abandoned outside the hospital but not inside.
	My final point concerns employment. We know that education and training for work and finding and keeping work are at the heart of patients' priorities. We must see the in-patient stay as a time when everything possible is done to keep a job or to get linked to the opportunities to give the person the chance of a job. At present, no one in the service thinks that it is their role to do that. We need mental health employment specialists whose task is just that. Of course, much of that work will go on outside hospital, but we need to keep people linked to those precious jobs and ensure that they do not lose them. That is extremely important in east London and must be just as important elsewhere.
	Are those ideas ambitious? Perhaps, but all have been tried at some time in some places and are not impossible, nor do they take a lot of financial investment. Mental health wards have had quite a lot of investment. Most of it has gone in staff salaries, which is perhaps no bad thing, but it needs to be better used. Let us hope that the new mental health foundation trusts will begin to innovate in the area of in-patients, just as we have seen foundation trusts do in acute care hospitals. I strongly support that move and I hope that we will be able to move away from some of the older national patterns of highly unsatisfactory care that we have now.

Lord Carlile of Berriew: My Lords, my noble friend Lady Neuberger brings to all the subjects on which she speaks and writes intellectual rigour, energy and compassion, and this is no exception. The House should be very grateful to my noble friend for raising the subject for debate tonight.
	Unlike the previous two speakers, I am not an expert in this field, but I have had experience very close to a service user. Like those speakers, I have some interests to declare. I was chairman of the scrutiny committee on the draft Mental Health Bill, which has been kicked into the long grass, as the House knows. I have been involved with a number of mental health charities and I am the president of the Howard League for Penal Reform, which, unfortunately, has a very large clientele of 77,000 people in prison at present, of whom approximately one half suffer from a mental illness.
	The subject that we are debating tonight is unfashionable but, in my view, it is the most important subject in the health service today. The popular newspapers, the red tops, are not given to running campaigns for improvements in mental health services. I was very sorry indeed to see that that great boxer, Frank Bruno, was suffering from severe mental illness, but that gave us an opportunity to see the red tops engaging in the subject. They were very good at it when they were dealing with Mr Bruno. I wish that they did it more often. I wish that we could see campaigns for child and adolescent mental health services from the popular newspapers in this country, just as we see campaigns for cancer care and heart care.
	Everyone in this House will have had the experience of visiting a very sick or dying relative in hospital—someone with a physical illness. It is all very definable, is it not? The relative has an illness that has a name. The symptoms can readily be looked up on the internet or in a dictionary. The doctors can usually give a pretty clear prognosis. Above all, the patient knows from what he or she is suffering. When they go to visit, the relatives can acquire that understanding. They can take advice and follow it relatively easily.
	With mental health, it is quite different. Most—certainly many; I should not say most—people in acute mental health wards do not necessarily accept that they are ill at all. They sometimes feel that they are being unfairly incarcerated by the law. They sometimes suffer from delusions and severe psychotic episodes. It is very difficult to explain to some, for they will not be able to understand the nature of their illness. It is just as hard for their nearest and dearest. People who visit patients in acute mental health wards often feel angry with their relations because they are not being reasonable or behaving like other members of the family. Our health services do very little really to explain not only to the patient, for whom it may be difficult, but to their friends and relations exactly what is happening to them. It really is time that we treated mental illness like every other illness—like measles, mumps, leukaemia, or any other definable diagnosis—but I suspect that we are still decades away from being able to treat mental illness in that way. I regard this kind of debate as a catalyst in that process and as an opportunity for non-experts such as me to make a plea for better services.
	Many studies have been done on mortality from mental illness, and they are very shocking. Lawrence, Holman and Jablensky found that mortality among the mentally ill in Western Australia is two and a half times that of the general population. Similar studies have been done in the United Kingdom, Michigan and elsewhere. The messages that they send to us all is that mental illness is as potentially fatal as almost any other illness, and more fatal than most. Of course, the tragedy is that, in many cases, people who are mentally ill do not die because their bodies give up working; they die at their own hands, all too often.
	When so many people are dying at their own hands when they are not suffering from a physical illness, surely it must be logical that there are better ways of preventing them from losing their lives in that way. My plea is for services to be provided in acute care to plan better outcomes. The noble Baroness, Lady Murphy, for whom I have great admiration, spoke of services in London as being, frankly, very poor. I think I heard her say that she would be hard put to think of a real exemplar of good practice. I will give her one that we saw on a visit of the scrutiny committee on the Mental Health Bill. It was the adolescent unit at the Bethlem Hospital, which is part of the Maudsley. It is, however, very small. It has a very small number of patients, and a school where they can take all their examinations. But you will be very hard put to find services like that if you go out of the Bethlem and out of London.
	The committee visited the equivalent facility in Cardiff, but frankly it was in appalling buildings and depended entirely on the angelic efforts of one middle-aged man who was in charge of the teaching in that school. Adolescents who are acutely mentally ill may lose two, three or four years of education, but if they come out of hospital, as we hope they will in due course, having lost that education, it is almost impossible for them to recover any kind of normal life unless they are very resilient and acquire a deep understanding of their illness.
	My plea is that services should be provided to enable young people to return to normal life. I have been involved in a particular small charity in Wales that seeks to provide—it is doing quite well—aftercare services for young people coming out of mental health wards. It does such things as teach them to cook again and to write a CV and obtain a job. But an organisation such as that—it is called Rekindle—has no public money because the public sector is so unimaginative in what it does with the money going to mental health services. Far too much is lost in bureaucracy, and a ludicrous amount is lost in maintaining buildings that should have been destroyed 20 years ago and reduced to smaller units. There are also terrible staff shortages.
	I want to say one thing about the mental health Bill. We know that the Government intend to introduce a new Bill, which is merely an amendment of the Mental Health Act 1983. I plead with them that we should not find ourselves getting bogged down in the Michael Stone question all over again. Mental health is not about a small number of people who unfortunately are not cured, are released from hospital, possibly by mistake or maybe by negligence, and commit terrible acts. It is tough to say so, but we can say it in this place because we are not elected: those kinds of accidents happen from time to time. We must talk about the real questions in mental health and not the headline questions, such as Michael Stone.
	I should also like to make a plea for better CAMHS—child and adolescent mental health services—provision. I have three short points to make. First, no child or adolescent should go into a mental health ward that is not completely age appropriate, wherever he or she is in the country. That is not yet the case. Secondly, there should be universal quality of care for mentally ill children and adolescents. It should not matter that they live in Birmingham or Berriew. In Berriew, there will be very little provision. In Birmingham, there will be rather more. It is not universal at the moment. Thirdly, the quality of mental health care for children and adolescents should be consistent. It is not. One of the reasons for that is therapists are being asked to give therapies for which they are not qualified. It is not satisfactory. A huge amount needs to be done, but we should never lose sight of the fact that this is an area of acute care and extreme suffering. I hope that this debate will help towards better standards.

Lord Ramsbotham: My Lords, like the other speakers, I, too, should like to the thank the noble Baroness, Lady Neuberger, for obtaining this timely debate on a subject on which, as she has already indicated, we share a joint interest as advisers to the trustees of the Sainsbury Centre for Mental Health. She persuaded it to invite me, so I follow her. My particular interest in going there is because the Sainsbury Centre for Mental Health has recently announced that it will concentrate its activities on the treatment of mentally ill people in prison and the problems of finding employment for mentally ill people—two hugely important and sadly neglected subjects.
	It may seem rather perverse to raise in-patient care in acute mental health wards for people who are acutely ill and for whom there are no acute mental health wards in prisons. I do so because until 2004 the Prison Service had its own healthcare for which it paid. In 1995, when I took over as Chief Inspector of Prisons, I was amazed to find that prison healthcare was not in the hands of the NHS. After all, all prisoners came from the NHS and would go back to it when they left prison. So why did they go into a sort of medical limbo when they went into prison? That seemed particularly perverse. Prisons, when people are locked up, present an opportunity for identification and treatment of problems both physical and mental. Therefore, to suggest that they had left the care of the NHS to go into this limbo suggested, as I was soon to discover, that that opportunity was not being seized.
	In my first inspection of Holloway, which I was told was the largest women's psychiatric prison facility in the country, I discovered large numbers of seriously ill women who were utterly neglected with totally inadequate services. That set the tone for what I found. As a result, in 1996, I produced a paper called Patient or Prisoner, which recommended that the NHS should take over responsibility for those people. Prisons are a public health issue. The health of people when they come out of prison matters to the public. Therefore, it is irresponsible for the Prison Service not to make arrangements to deal with their health while they are inside.
	So it was that I was very interested in this debate and I was particularly interested in the reports of the Sainsbury Centre. The noble Baroness, Lady Neuberger, has already referred to a follow up to the original report, called The Search for Acute Solutions, and I should like to quote three short messages from that report which have a great resonance with what goes on in prisons.
	"It is important that some short-term investment is made by leaders and managers to enable staff to participate in bringing about change given the potential for long-term gain derived from a more effective service. This does not necessarily mean money. Using existing resources differently and flexibly is possible but good management and leadership are necessary to achieve this. Advanced unit-wide planning, sound organisation, consultation and communication are required so that staff can feel comfortable about taking time to develop and implement change".
	Hear, hear to that! Strong leadership, strong management and strong direction, to my mind, are more important than money. We have got to see that existing facilities are used better. I was horrified to find when inspecting prisons that there is only one secure unit in the whole system: it is at Aylesbury and it is used as a classroom because it has not even got a psychiatrist there for the young offenders.
	Secondly, as my noble friend Lady Murphy has already mentioned, the report states:
	"Inactivity and boredom can delay recovery and can sometimes cause increased levels of aggression and frustration".
	Hear, hear to that! What on earth is going to be done for acutely mentally ill people left locked up in prison cells all day? It is doing absolutely nothing for them except, as my distinguished psychiatrist, Dr John Reed, used to say frequently, merely making them worse.
	Finally, the report states:
	"However, whatever the place that acute in-patient care comes to occupy, there can be no excuse for poor environments and low-quality services.
	Hear, hear to that!
	Noble Lords may wonder what numbers we are talking about because the numbers in the NHS are huge and the numbers in the Prison Service may not be. Let us look at it proportionally to start with. If you take the percentage of people who suffer from two or more mental disorders, in the general population it is 5 per cent of men and 2 per cent of women; move to prisons and the figures show that 72 per cent of males sentenced and 70 per cent of females sentenced are suffering from two or more mental disorders. Moving on to neurotic disorders—sleep, worry, anxiety, depression and so on—the figures are 12 per cent of men and 18 per cent of women in the general population, but 40 per cent of males and 60 per cent of females in prison. As to the numbers of people who need acute treatment—the ones suffering from psychotic disorders—the figures are 0.5 per cent of men and 0.6 per cent of women in the general population, but 7 per cent of all males and 14 per cent of all females sentenced in the prisons are suffering to that degree. And yet there are no acute mental health wards for them to receive treatment.
	To put the numbers into a more reasonable proportion than mere percentages, perhaps I may quote an article by Dr Adrian Grounds, written in 2004. He states:
	"The scale of the problem is huge. Based on the best research we've got, it may be that about 4% of the prison population need to be in hospital beds, and, in current terms, that means that something in the order of 3,000 prisoners, possibly up to 3,700"—
	which is much more likely now given the increase in numbers—
	"need to be in a psychiatric hospital".
	That is a large number. The trouble is—and I fully sympathise with the NHS and all the people who plan it—that we are not coming at this problem from a good starting point. Because prisons were not part of the NHS, the needs of people in prison were not included in NHS estimates. Therefore a large number of people were coming out—remember that all except just over 30 people in prison will come out—bringing these needs with them into the community, with no arrangements made for them.
	As a result, to go on with what Dr Grounds said:
	"We commonly see mentally ill men being released at the end of their sentences who, at the very least, should go to suitable accommodation, be registered with their GP and have had follow-up by their local mental health service arranged. Distressingly often, and notwithstanding efforts by their probation officers, they leave with no address, only an instruction to present themselves as homeless to their local housing authority. In the absence of an address, the relevant mental health team either cannot be identified, or will refuse to see the patient, or both. There will be no GP registration. Housing authorities may refuse to accept a prisoner on their waiting lists before he is released because he is not potentially available to take up a tenancy should one arise".
	The reason I mention all this is not merely in connection with the acute bed report. The fact is that in our society, as a responsibility of the NHS, are people whose treatment in prison and subsequent treatment after they leave will make them candidates for the over-stretched acute beds and whose needs should be looked at, as well as the people who should be identified by courts and prisons and referred to the acute system even earlier. My contention is that although the cost is large—and I do not pretend that it is not—we cannot afford not to do this, because the cost of not doing it will be greater.
	It seems to me perverse that the Prison Service has made £126 million over three years available to treat the 200 to 300 people said to be very seriously disturbed, which works out at £180,000 per person, whereas it has made only £122.5 million available for healthcare, which means £817 only for all the others, a large number of whom are acutely ill. Therefore, I hope that in responding to this very important debate, the Minister will not forget the needs of this part of the population, which is the latest addition to their budget.

Baroness Barker: My Lords, I, too, congratulate my noble friend Lady Neuberger on such a timely debate and, as one might have expected in a debate secured by her, on assembling such a wonderful list of contributors.
	I say that the debate is timely for two reasons. We await with eager anticipation whatever is due to emerge as the new mental health Bill. My noble friend Lord Carlile said that the draft Bill had been kicked into the long grass but only a few weeks ago, the Minister in another place, Rosie Winterton, assured Members of both Houses that a Bill would be introduced in this Session and that, contentious as it might be, it would not be subject to pre-legislative scrutiny.
	There is an element in the timing of tonight's debate that is slightly unfortunate. The Audit Commission will tomorrow publish its report on managing finances in mental health. Unfortunately, the report is embargoed until tomorrow, but I suggest that it will make extremely interesting reading.
	I had the privilege of being on the Joint Committee on the Draft Mental Health Bill, chaired so ably by my noble friend Lord Carlile. As we sat there week after week, listening to people tell us how much they hated the Government's draft proposals, the evidence of one young man stood out. He came to talk to us about the Child and Adolescent Mental Health Services; he had been a service user. He talked about just what being subject to compulsory treatment does to somebody and how disempowering it is. He then talked about what it was like to have been subject to compulsory treatment—to be sat in a ward where nothing much is happening, one does not know when one will get out, it is hot and one cannot go outside, and there is an immense amount of boredom. He said to us, "You know that in that situation, the smallest of things can tip you over into a crisis—not being allowed to decide which TV programme you can watch or being locked up with people you don't like". For the first time, he began to make me understand what this whole system does to individuals and why it does not work.
	It is true—and I am sure that the Minister will tell us in his reply—that there have been increased resources for mental health. There has been a 10 per cent real increase in investment in adult acute inpatient facilities since 2001–02. At the same time, there has been an overall increase of 25 per cent in adult mental health services. As my noble friend Lady Neuberger said, problems that we thought would be addressed by crisis resolution teams, assertive outreach teams and so forth have not managed to decrease the number of people being referred for acute services.
	What then can one draw from this welter of reports, all of which indicate problems in acute mental health services? Perhaps one of the first things is that care plans are not implemented. If an emphasis were placed on involving users in the design of care plans and in their implementation, many of the acts of violence and so forth to which my noble friend Lady Neuberger referred would not happen, because the source of such aggravating problems would have disappeared from the lives of people who were already feeling pressured and largely ignored.
	Secondly, links between the acute and community sectors must be improved. Throughout the rest of the acute services within the NHS, much greater emphasis is now put on the process of rehabilitation and discharge and much greater emphasis on the transition from an acute setting to a community setting. I was very interested to listen to what the noble Baroness, Lady Murphy, had to say—I always am—about how community teams and acute teams never see the person they are treating in the other setting. If they were to do so, that process of transition and discharge could be made more accessible. There could be far fewer avoidable re-admissions.
	My noble friend Lord Carlile was absolutely right when he talked about this as being an illness, but one that we simply do not treat in the same way as any other illness. For example, we would not in any other setting where people were receiving treatment put together young people and old people or men and women. It is staggering that, despite the investment in resources, adult wards are still receiving children as young as 14. That is inappropriate, in some cases dangerous, and, to them, it is frightening. We would not let it happen in any other healthcare setting.
	What can we take from these many reports that might be hopeful? One thing in particular stood out for me—the emphasis on access to talking therapies. When my noble friend Lord Carlile and I were privileged to go to those centres in south London, we met a marvellous assertive community outreach team. But we also met service users who told us that they were going into debt in order to pay for talking therapies which they needed and could not access any other way. Individual people should not be driven to the point of knowing that there is a source of healthcare that they need and then having to pay for it. It does not make sense for the NHS either, because the lack of access to talking therapies in community service almost inevitably leads to a build-up of demand on the acute services when people reach a crisis point.
	Much is going on and much notice is being paid in the world of mental health to Professor Layard's recommendations about the use of cognitive behavioural therapy for depression. We should also recognise that NICE has recommended that cognitive behavioural therapy should be available for people with schizophrenia. The lack of access to that is taking a great and unnecessary toll on many of the acute services within the NHS. If one were to talk to many of the professionals, they would say that that would be one thing that the Government could do that would make a real difference to the picture overall.
	My noble friend Lady Neuberger and others talked of the ongoing problem of the disproportionate numbers of people, particularly young men, from black and minority ethnic communities, who are in our acute mental health services. I sympathise with those from the Sainsbury Centre for Mental Health who wonder how often they have to raise this before the issue is really taken on board, because they have been quite explicit that what we are talking about is the impact of institutional racism within mental health services, disproportionately adversely affecting one part of our community.
	Many times when people talk about mental health, they talk about the much-forgotten need to remember that the physical health of people with mental health problems should be treated hand-in-hand—and so frequently it is not. Much of what the noble Lord, Lord Ramsbotham, said played well into that point. We know that there are many people sitting on acute wards who are smoking and engaging in other activities that are simply not conducive to all-round physical health. That is a contributing factor overall.
	Finally, I want to raise one question that is central to all of this. We are at a point with our mental health services when professionals are working with outdated legislation and there is a great deal of uncertainty and anxiety about the appropriateness of what legislation may come down the track shortly. We have a great deal of good advice and guidance in the national service framework, much of which is not being implemented. In many ways, the world has moved on. Is it not now time to ask what acute mental health services are for and where they should be based and how they should be configured to achieve the optimum therapeutic outcome? If we did that, we might perhaps abandon some of the PFI building plans, which have been so dominated by the acute sector. We might free up resources to spend on some of those innovative services that noble Lords have mentioned. We might invest in the voluntary sector rather than taking services away from them, as I understand to be the case. Organisations such as Mind are struggling to fulfil their advocacy role, among others. When we answer the question of what our acute services are for, we shall begin to see the beginning of the end of those inappropriate buildings, of staff working in isolation from those involved in provision of community services, and we shall begin to answer the many questions raised by the many reports.

Earl Howe: My Lords, the noble Baroness, Lady Neuberger, has done us a service in tabling this Motion today. I pay tribute to the way in which she so ably articulated many of the serious and widely held concerns about in-patient mental health care. I listened to her with a considerable measure of agreement, as I did to all other noble Lords who have spoken.
	We have heard a lot of worries and criticism, one way and another, but I shall begin with a brief reassurance to the Minister. I am the first to recognise—as, I am sure, are we all—that the resources directed by the NHS towards mental health in general have risen considerably in recent years. I am also the first to recognise that, as a result of this investment, we are seeing gradual improvements in the service. Nevertheless, measuring the quality of mental health care, like any other sort of healthcare, is not about inputs but about outcomes. That was why the noble Baroness was so right to focus our minds on the patient experience. In this field of care, almost par excellence, the patient experience defines the standard.
	In preparing for this debate, I have been looking at a number of recent surveys: the 2004 survey published by the Sainsbury Centre for Mental Health, the Mind Ward Watch survey of the same year, the National Audit of Violence in 2005 and the Sainsbury Centre report, The Search for Acute Solutions. There is an awful lot of information out there, almost a bewildering amount, and it is quite easy, if we are not careful, to get bogged down in the detail. What we need to do, as shapers of policy in the broadest sense, is take a step back and look at the direction of travel, define our objectives and try to identify the key trigger points that are likely to lead to the attainment of those objectives.
	For a start, we need to do exactly what the noble Baroness, Lady Barker, suggested: take a long hard look at what we want in-patient mental health care to look like, and what we want it to do at a time when we are seeking to deliver greater amounts of healthcare in the community. In other areas of the NHS we are seeing health policy develop in a way that reflects modern values: no longer the pervading assumption of "doctor knows best", but rather professional attitudes that credit patients with being individuals who know their own minds, and who may actually have personal preferences. Autonomy and choice should be just as much a part of mental health care as of any other sort of care.
	If we truly believe that, a number of things have to follow. We need to improve the commissioning of in-patient care. We need to create opportunities for people to make genuine choices about where they get acute care, and what sort of care they receive when they come to need it. Flowing from that, we must make in-patient care responsive to the wants and expectations of patients who elect to receive it.
	I am sure most noble Lords here have seen the inside of an in-patient mental health ward. I have visited a number—not, I may add, as a patient—and I cannot say that I found it an uplifting experience. There were good, sometimes excellent, staff, but the prevailing mood in those places could be summed up as a mixture of intimidating, institutional and crashingly dull. Where we find, as we did in the Mind Ward Watch survey, 53 per cent of in-patients saying that the ward environment did not help their recovery, a quarter of patients saying that they felt unsafe and half saying they had been abused in some fashion, we know there is a huge amount left to do.
	Too often cognitive behavioural therapy is recommended but not available. Too often we have children being treated for mental health problems on adult wards because children's facilities are not there. Nearly 3,000 bed days every month are accounted for in that way. With the recent tightening in PCT funding, we are seeing in some places not an elimination but a reintroduction of mixed-sex wards—the very opposite of what is desirable.
	If we look at the trends over the past few years, the number of in-patient beds has gone down, yet the demand for beds has stayed the same; hence the bed occupancy figures rightly mentioned by the noble Baroness, Lady Neuberger. In some areas of the country, particularly London, staff shortages are acute. Very often, the worst shortages are where the need is greatest; London again being the prime example. Part of the difficulty of in-patient care—a major part—is that many staff prefer to work in a community setting, and they vote with their feet. Some staff migration of this kind is needed to form up the new crisis resolution teams and for treating patients at home; but too much of it leaves the acute wards depleted, and it is very difficult in those circumstances for the staff who are left behind, however good and caring they are, to deliver an optimal service.
	It is against that background that I say to the Government that should a new Mental Health Bill be introduced which sanctioned in-patient treatment even where there was no illness to treat, or which resulted in significantly more people being detained compulsorily, that would be a recipe for huge problems. The audit of violence contains all the warnings we need on that score. We all know that investment needs to be channelled into community services. But as Anna Walker said recently, more attention must be given to in-patients. Something has to be done to recruit and retain good staff in those acute settings, and to make them feel that it is a job that is really valued and worth while. Most of the experts agree that part of the solution lies in new ways of working, so as to create more face-to-face time between staff and patients. There are models of good practice out there from which we can draw.
	Allocating the health budget is all about fixing priorities. So let us never forget the cost of mental illness in terms of social exclusion and the drain it represents on the economy, amounting to many tens of billions. It is an area of ever growing importance in our nation's health, on which we look to the Government to give a lead.

Lord Warner: My Lords, I am sure that we are all grateful to the noble Baroness, Lady Neuberger, for giving us this opportunity to discuss improving mental health services, especially in-patient care. We should not forget that the shift towards treatment within communities has brought enormous benefits for many thousands of people, but I recognise only too well—as a number of noble Lords have said—the importance of better meeting the needs of those who still need care in hospital. We are quite sure that community teams are having an impact both on admissions to hospital and on better handling through to discharge.
	Let me begin by addressing directly the questions asked by the noble Baroness, Lady Neuberger, on the two reports that she mentioned, which were both published about a year ago. We welcomed both reports. Indeed, the Sainsbury centre report was commissioned by the National Institute for Mental Health in England, which is part of the Department of Health. We openly acknowledge the concerns that both publications identified and that the noble Baroness so elegantly described. In fact, by this time last year, we had already begun a significant programme of work to improve in-patient mental health care.
	In December 2004, Professor Louis Appleby, the national director for mental health, published his report on progress with the National Service Framework for Mental Health. He outlined a comprehensive modernisation programme embracing capital investment, tackling drug misuse and violence, improving staff recruitment and retention, and better integration with community services. There is a strategy, and that strategy was set out. I believe we have made some real progress, especially in those wards where needs are greatest. I recognise that there is still too much geographical variability for anyone to be comfortable. The noble Earl, Lord Howe, is absolutely right in that regard.
	We are now in the second phase of funding to support the Enhancing the Healing Environment initiative of the King's Fund, which provides better healing environments and a better overall experience for patients. I am not claiming that that is the end to all the problems in some in-patient environments, but it is a good start and we will continue to make progress in the area. I pay tribute to the noble Baroness, Lady Neuberger, for her work in the King's Fund in starting that initiative.
	We have significantly increased capital investment in mental health services. On top of the £1.6 billion capital spent by mental health trusts between 2001 and March last year, we have since made available another £190 million to improve in-patient accommodation and ensure that each mental health trust has access to an "appropriate place of safety" for assessment of people brought in under the Mental Health Act by police. I recognise that that capital investment is not the end of the world, but it makes progress in improving the quality of life for the large number of people who live in that accommodation. It also makes the job of staff easier in that regard.
	The latest round of capital allocations announced in February is particularly good news for mental health trusts, which receive a 50 per cent average increase in operational capital compared to the previous financial year. That is double the level of increase in operational capital nationally. That funding goes directly to mental health trusts, allowing local decisions on how best to modernise those facilities. The investment is paying off for patients. A good example of a new, well designed unit is the award-winning Woodhaven mental health unit in the New Forest. The day area has large floor-to-ceiling windows, which optimise the natural light. Outside the building itself, there is direct access to large landscaped gardens and water features. All in all, it is a good physical environment to support service users' recovery. Change is happening on the ground, perhaps not as fast as many of us would like, but the money is going in and showing in new facilities being brought into use.
	Let me reassure the noble Baroness, Lady Barker, that a survey published recently showed that planned spending on mental health services in England rose by 3 per cent in real terms in the last financial year. The Audit Commission report may be interesting, but not necessarily in the way that she expects. Since 1999, spending on mental health has risen in real terms by over a quarter. The UK now has one of the highest proportions in Europe of its overall health budget devoted to mental health. I am grateful to the noble Earl, Lord Howe, for his recognition of what the Government have done on investment. While money is not everything, it is difficult to improve services without more investment. However, we have to recognise that we are dealing with a long period of neglect of investment for this service area, and it takes time to make progress.
	Three mental health trusts have already been approved for foundation trust status, which is good news for them and their patients, and I am confident that we will see more in the future. That shows that mental health trusts are effective financial managers of their resources. They use their resources well and have a business planning approach. Increased investment is important, but I recognise that there are other issues, as noble Lords have said. We have developed and published guidance that supports in-patient care and the staff who provide it, often in very challenging circumstances. That includes advice on managing disturbed behaviour.
	Let me say a few words to respond to the many concerns expressed this evening about how staff deal with disruptive and violent behaviour. All mental health service providers should have clear policies, procedures and training to ensure that incidents of aggression and violence are managed safely and effectively. Development of policy and training is supported by the National Institute for Clinical Excellence's guidelines on the management of violence in in-patient settings published in 2005. The management of violence initiative has also produced proposals for a national accreditation and regulation scheme for trainers and programmes of education and training later this year. These programmes are starting to have an impact on staff and on the environment in which patients are cared for. To ensure progress, the Healthcare Commission will include safety and the physical environment in its improvement review on acute in-patient care, commencing in autumn 2006 and reporting in 2007. The National Patient Safety Agency's safer wards project will potentially help to deal with disruptive and aggressive behaviour in wards.
	The importance of better in patient care was also recognised by the Chief Nursing Officer in her recent review of mental health nursing. Her report made a number of important recommendations relating to clinical practice and staffing arrangements. For example, she recommended that the amount of time spent in direct contact with patients could be improved by introducing therapeutic time initiatives, whereby administrative tasks will be put aside for a period to allow nurses and patients to have protected time together. The noble Baroness, Lady Neuberger, mentioned that important issue. We know that that can work. The Oxfordshire Mental Healthcare NHS Trust introduced protected time for an hour and a half every day. Both staff and patients welcomed it and the number of complaints at the trust has gone down. So there is good evidence that such an approach actually works.
	Other recommendations relate to strengthening career structures in in-patient care to retain experienced and well qualified staff and ensure that those who do not have professional qualifications are suitably developed and supervised. Although long-term vacancies for mental health nurses have fallen over the last two years, we recognise that that remains a significant challenge in some geographical areas, and so guidance has been published on improving recruitment and retention. The workforce development strategy to support the national service framework has helped to secure considerable increases in staffing, including in in-patient wards.
	I hope that noble Lords would accept that in-patient care cannot, and should not, be neatly boxed off from care outside hospital. The two are inextricably linked. So I would like to stand back and look at the bigger picture of developments in mental health care, because they have an impact on in-patient care.
	The national service framework is an ambitious 10-year plan, and I believe that it is working. The significant extra investment that I have mentioned means that we now have over 20 per cent more psychiatric nurses and over 50 per cent more psychiatric consultants than we had when we took office in 1997. By any stretch of the imagination, those are large increases in the professional staff available, both in in-patient care and for outpatient care. It is a good hard fact that the suicide rate has fallen to its lowest recorded level and is now one of the lowest in the European Union.
	There are over 700 new community mental health teams working in the community. As a result, crisis resolution and home treatment teams are contributing to a significant reduction in emergency bed days in mental health in-patient units. Since the 1990s, there has been a fourfold increase in the use of modern anti-psychotic medication. It is a tribute to mental health services that last year's survey by the independent Healthcare Commission showed that most patients expressed high levels of satisfaction with their services. All of this impacts on the demand for in-patient care and, without such advances, I would suggest that the pressures on our in-patient estate would be much greater.
	A number of noble Lords mentioned psychological, or "talking", therapies. I remind the House that the Secretary of State for Health recently announced the next stages of our programme to help more people benefit from psychological therapies. It will begin with two national psychological therapy demonstration sites, in Newham and Doncaster, linked to a national network of local psychological therapy improvement programmes.
	Real progress is being made; however, I recognise that the delivery of services in often very difficult circumstances means that we must congratulate and pay great tribute to the staff who carry out this work—day in, day out. I do not diminish the challenges that they face. There is always more to be done, and we are clear that the remaining commitments in the national service framework need to be met. In the context of in-patient care, there is one other issue that I want to mention; namely, improved mental health care for black and minority ethnic communities, which is at the top of the national work programme.
	We know that people from some ethnic backgrounds are significantly more likely to be admitted to hospital, more likely to be detained and more likely to reach hospital through the criminal justice or social service systems. Once in hospital, they are also more likely to be subject to measures such as seclusion and restraint. We face up to and acknowledge that.
	The reasons underlying those facts are complex but the problem has effectively been left unchallenged by successive Governments for decades. Last year we published a comprehensive five-year action plan for delivering race equality in services. Ridding the system of inequalities once and for all might not be easy but I believe that we should never settle for less. We will continue to work in this area.
	I recognise that I have not responded to all the points raised by noble Lords but I shall do so in writing. I reassure the noble Lord, Lord Ramsbotham, that I am well seized of the relationship between the Prison Service's health needs and the NHS. He will recall that the Government transferred responsibility of those often underfunded health services to the NHS. We have put the NHS in a position of responsibility to people who are in prison and are being discharged from it. I do not claim that everything is perfect in the system but we have now started to move in the right direction in this area.
	What I have described today is a serious, radical and long-term programme of modernisation that is aimed at in-patient care just as much as care of any other sort. Mental health has never been higher up the Government's agenda. I share the view of the noble Earl, Lord Howe, that improving the commissioning of mental health care is vital. That is why improved commissioning is such a vital part of NHS reform. As I have described, the result that we have so far produced is record increases in investment and staffing and—thanks to the efforts of staff who were in place and the newcomers to the service—front-line services have become much more responsive to the needs of the people who use them. I recognise that we are still some way from fulfilling all of our ambitions. Until we do, the top of the agenda is exactly where mental health will stay for this Government.